ModifiedMass General Brigham Health PlanPolicy N/A

Bariatric Surgery Coverage Criteria (Primary and Revisional Procedures)

Defines Mass General Brigham Health Plan medical necessity, prior authorization, and coverage stance for primary and revisional bariatric surgical procedures for plan members, including variations for Medicare Advantage, MassHealth/ACO, OneCare and SCO members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyBariatric Surgery Coverage Criteria (Primary and Revisional Procedures)

Policy CodePolicy N/A

Change TypeAdded procedures (SADI-S, TORe) and updated authorization variations

Effective DateN/A

Next Review DateN/A

Key ActionProviders must request prior authorization and document medical necessity using InterQual criteria (modified by the plan).

SourceLink

POLICY UPDATE CHANGES

Added coverage for single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S).

Added transoral outlet reduction (TORe) to the list of approvable revisional procedures.

Updated prior authorization table and added OneCare and SCO variation language.

7procedure types listed for adults

Requiredauthorization requirement

S2083code allowed without auth (band adj.)

C9785

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

code not payable (ACO)

InterQualmedical necessity source

Coverage Criteria for Bariatric Procedures

Primary and Revisional Bariatric Surgery (Adults)

Covered when InterQual (modified) medical necessity criteria are met and prior authorization obtained:

Adult primary and revisional procedures

Procedures: 1. Roux-en-Y Gastric Bypass (RYGB) 2. Gastric Bypass using Biliopancreatic diversion with duodenal switch (BPD/DS) 3. Sleeve Gastrectomy 4. Laparoscopic adjustable gastric banding (LAGB) 5. Adjustable Gastric Banding (AGB) (repair, removal, revision) 6. Revisional procedures including: a. Revision of gastroduodenal anastomosis with reconstruction; b. Revision of gastrojejunal anastomosis with reconstruction 7. Transoral outlet reduction (TORe) following RYGB 8. Single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S)

Primary and Revisional Bariatric Surgery (Adolescents)

Covered for adolescents when InterQual pediatric/adolescent medical necessity criteria are met:

Adolescent procedures

Procedures: 1. Roux-en-Y Gastric Bypass (RYGB) 2. Sleeve Gastrectomy 3. Adjustable Gastric Banding (AGB) (repair, removal, revision) 4. Revisional procedures including: a. Revision of gastroduodenal anastomosis with reconstruction; b. Revision of gastrojejunal anastomosis with reconstruction

This policy does not cover primary endoscopic bariatric surgery procedures. Examples of excluded techniques include natural orifice transluminal endoscopic surgery (NOTES), transoral gastroplasty, endoluminal vertical gastroplasty, endoscopic sleeve gastroplasty, and use of endoscopic closure devices (for example, the Apollo OverStitch Endoscopic Suturing System).

In addition to endoscopic suturing procedures, the following are expressly listed as exclusions and are therefore not covered as primary bariatric interventions under this policy: gastric balloons and long limb gastric bypass. Because these techniques are excluded, claims for primary endoscopic bariatric procedures (for example, endoscopic sleeve gastroplasty) and gastric balloon placement will be considered not medically necessary and not payable.

Informational and Billing Codes

Informational CPT/HCPCS codesmixed

43644	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less).
43645	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption.
43659	Unlisted laparoscopy procedure, stomach. (May be used to describe SADI-S; secondary review if used for other procedures.)
43770	Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components).
43771	Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only.
43772	Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only.
43773	Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only.
43774	Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components.
43775	Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy).
43845	Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (biliopancreatic diversion with duodenal switch) (50 to 100 cm common channel).

1–10 of 20

1/2

Age

Adult age rangeAdults 18 years and older (medical necessity determined using InterQual criteria)

Adolescent age rangeAdolescents 13 through 17 years (medical necessity determined using InterQual pediatric/adolescent criteria)

Source for age thresholdsInterQual criteria as referenced by Mass General Brigham Health Plan

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for bariatric surgery for most Mass General Brigham Health Plan product lines. Providers must request authorization before the procedure; failure to obtain prior authorization may result in claim denial. Note: certain codes (e.g., S2083) are allowed without prior authorization for specified plan types per plan-specific rules.

Authorization required for Commercial and Qualified Health Plans, Mass General Brigham ACO, Medicare Advantage, OneCare, and Senior Care Options as indicated in plan-specific guidance.
No prior authorization allowed for code S2083 in certain plan types where listed (see coding guidance).

Documentation Required

Authorization Documentation and Criteria Source

Mass General Brigham Health Plan determines medical necessity for bariatric surgery using InterQual criteria (modified to include coverage for SADI-S and TORe). For Medicare Advantage members, CMS NCD/LCD guidance supersedes InterQual where applicable. Providers must submit documentation that demonstrates the member meets the applicable InterQual or Medicare criteria to support authorization.

Background

Bariatric surgery refers to non‑cosmetic surgical procedures performed to treat morbid obesity. This policy addresses coverage for both primary and revisional bariatric procedures for eligible members; primary procedures are the initial surgical operations intended to produce weight loss, while revisional procedures address complications or inadequate treatment effect from prior bariatric surgery or convert one procedure type to another. The policy’s coverage determinations and prior authorization requirements apply to the full scope of listed primary and revisional bariatric operations.

Definitions and Procedure Terms

Bariatric surgery

DefinitionBariatric surgery: non-cosmetic surgical procedures used in the treatment of morbid obesity.

Scope in this policyIncludes primary and revisional procedures (e.g., RYGB, sleeve gastrectomy, LAGB, BPD/DS) when authorized and medically necessary.

Authorization requirementCoverage is limited to listed bariatric surgical procedures when prior authorization is obtained and InterQual medical necessity criteria are met.

Conversion Surgery

DefinitionConversion Surgery: a surgery that changes one type of procedure to a different type of procedure.

ContextMay be performed when previous procedure type is altered to achieve different anatomic or physiologic outcomes; considered distinct from corrective procedures.

Policy Summary

PayerMass General Brigham Health Plan

PolicyBariatric Surgery Coverage Criteria (Primary and Revisional Procedures)

Policy CodePolicy N/A

Change TypeAdded procedures (SADI-S, TORe) and updated authorization variations

Effective DateN/A

Next Review DateN/A

Key ActionProviders must request prior authorization and document medical necessity using InterQual criteria (modified by the plan).

SourceLink

On This Page

InterQual is the primary criteria source; access via the Mass General Brigham Health Plan provider website (Resources > InterQual Criteria Lookup).
For Medicare Advantage members, reference NCD Bariatric Surgery (100.1) and LCD L35022.

Note

Preoperative Weight Loss Program Evidence

Preoperative supervised weight loss programs have mixed evidence regarding impact on bariatric surgery outcomes. Hayes and other evidence reviews have evaluated preoperative supervised weight loss programs and endoscopic procedures; these references inform the Plan's expectations but do not mandate a uniform pre-op weight loss program in all cases. Providers should include any preoperative weight management documentation submitted for authorization; the Plan will consider this evidence alongside InterQual or Medicare criteria.

Hayes: Impact of Preoperative Supervised Weight Loss Programs on Bariatric Surgery Outcomes (Aug 10, 2017).
Hayes evidence reviews and clinical guidelines (see References) inform but do not uniformly require supervised preoperative weight loss as a standalone authorization criterion.

Documentation Required

Documentation Sources

Clinical guidelines and evidence summaries commonly referenced for authorization decisions include MassHealth Guidelines for Medical Necessity Determination for Bariatric Surgery and society guidelines (AACE/ACE, ASMBS, perioperative nutrition guidelines). Include relevant citations and supportive clinical documentation with authorization requests to expedite review.

MassHealth Guidelines for Medical Necessity Determination for Bariatric Surgery (Aug 15, 2019).
Mechanick JI et al. Clinical Practice Guidelines for Perioperative Nutrition, Metabolic, and Nonsurgical Support (2019).
AACE/ACE and ASMBS guidelines listed in References.

Policy relevanceConversion procedures are recognized in the policy definitions and evaluated under InterQual-based medical necessity when applicable.

Corrective Surgery

DefinitionCorrective Surgery: surgical procedures addressing complications or an incomplete treatment effect of a prior surgery, without changing the type of procedure; may include reversal procedures that restore original anatomy.

ExamplesIncludes procedures to manage complications or to complete the intended effect of a prior bariatric operation; evaluated as revisional/corrective under policy criteria.

Policy handlingCorrective procedures are considered revisional and require authorization with medical necessity determined using InterQual criteria.

SADI-S

Procedure nameSingle-Anastomosis Duodeno-Ileal bypass with Sleeve (SADI-S)

DescriptionA bariatric procedure combining sleeve gastrectomy with a single duodeno-ileal anastomosis to produce both restrictive and malabsorptive effects.

Evidence and policy updateSADI-S is discussed in multiple systematic reviews and comparative studies cited in the policy and was added to the list of approvable procedures; 43659 may be used to describe SADI-S when criteria are met.

Endoscopic Sleeve Gastroplasty (ESG)

DefinitionEndoscopic Sleeve Gastroplasty (ESG): a minimally invasive endoscopic suturing procedure for obesity.

Evidence assessmentESG has been assessed in Hayes reviews and other evidence summaries cited by the policy (Hayes Clinical Research Response; Hayes Evolving Evidence Review).

Coverage stancePrimary endoscopic bariatric procedures (including ESG) are listed as exclusions and are not covered under this policy.