CurrentmediviewcurativePolicy MM-PNP-005

Bariatric Surgery Medical Necessity and Preoperative Requirements

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Defines medical necessity criteria, preoperative requirements, and covered bariatric procedures for Curative Health Plan members; applies to Medical UM Department reviewers and providers requesting authorization for bariatric surgery.

Policy Summary

Payermediviewcurative

PolicyBariatric Surgery Medical Necessity and Preoperative Requirements

Policy CodePolicy MM-PNP-005

Change TypeNo material change

Effective DateMar 22, 2024

Next Review Date

Key ActionObtain prior authorization demonstrating medical necessity and ensure one year of documented Mounjaro use (unless contraindicated) plus completion of a 6–12 month intensive behavioral program before surgery.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7named bariatric procedures considered medically necessary

1 yrrequired prior use of Mounjaro

6–12 morequired behavioral intervention

>40adult BMI threshold (severe obesity)

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CurrentmediviewcurativePolicy MM-PNP-005

Bariatric Surgery Medical Necessity and Preoperative Requirements

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Policy Summary

Payermediviewcurative

PolicyBariatric Surgery Medical Necessity and Preoperative Requirements

Policy CodePolicy MM-PNP-005

Change TypeNo material change

Effective DateMar 22, 2024

Next Review Date

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7named bariatric procedures considered medically necessary

1 yrrequired prior use of Mounjaro

6–12 morequired behavioral intervention

>40adult BMI threshold (severe obesity)

~40experimental/investigational procedures

Coverage Criteria for Bariatric Procedures

Initial adult bariatric surgery criteria

Covered when ALL of the following are met for adults:

Adult medical necessity: Patient is ≥18 years and has persistent severe obesity defined as either BMI >40 (or >37.5 for persons of Asian ancestry) measured prior to the preoperative preparatory program with documented failure of weight loss by medical management, OR BMI >35 (or >32.5 for persons of Asian ancestry) measured prior to the preoperative preparatory program in conjunction with at least one listed severe comorbidity (clinically significant obstructive sleep apnea; coronary heart disease with objective documentation; medically refractory hypertension despite ≥3 antihypertensive agents; insulin resistance or Type 2 diabetes mellitus; nonalcoholic steatohepatitis [NASH]; or idiopathic intracranial hypertension).see BMI thresholds

BMI measured prior to preoperative preparatory program

Preoperative medication: One year use of Mounjaro (Mounjaro) prior to surgery unless there is a documented intolerance or contraindication to Mounjaro use.1 year

Required unless contraindicated

Behavioral intervention: Participation in a 6–12 month intensive multicomponent behavioral intervention with documentation (monthly detailed weight history demonstrating 5% weight loss, dietary modification documentation, and physical activity modification documentation) OR participation in a 6-month multidisciplinary surgical preparatory regimen.6-12 months

Program must be intensive (≥12 sessions on separate dates) and occur within 2 years prior to surgery; program records may substitute for medical records for recognized commercial programs.

Psychosocial clearance: Psychosocial-behavioral evaluation and sign-off by a behavioral health professional OR participation in a 6-month multidisciplinary surgical preparatory regimen.

Required to identify risk factors for poor postoperative outcome

Adolescent bariatric surgery criteria

Covered when ALL of the following are met for adolescents who have completed bone growth:

Age/bone growth: Completed bone growth (generally age ≥13 in girls and ≥15 in boys).

Weight class/comorbidity: One of: Class III obesity OR Class II obesity with one or more qualifying comorbidities (insulin resistance/Type 2 diabetes; poorly controlled hypertension despite pharmacotherapy; obstructive sleep apnea confirmed on polysomnography with AHI or RDI >30; evidence of NAFLD; or idiopathic intracranial hypertension).

If OSA is asserted, confirmation by polysomnography required

Center evaluation: Evaluation at, or in consultation with, a multidisciplinary/adolescent accredited bariatric center (e.g., MBSAQIP accreditation or equivalent program components).

Documentation of center evaluation required

Preoperative requirements:

Planned two-stage bariatric procedure

A planned two-stage procedure is covered when ALL of the following are met:

Two-stage criteria: Initial BMI ≥50 kg/m2 prior to the first-stage bariatric procedure; the planned second stage occurs within 2 years following the primary bariatric surgery; the individual has been compliant with prescribed nutrition and exercise; and the individual meets medical necessity criteria at the time of the second-stage procedure.BMI ≥50; second stage ≤2 years

Repeat, revision, and conversion surgery criteria

Repeat or revision bariatric surgery is considered medically necessary when the following criteria are met:

Repeat/conversion after inadequate weight loss: Conversion or repeat surgery is considered medically necessary for members whose initial bariatric surgery was medically necessary and who have not achieved adequate success, defined as sustained loss of more than 50% of excess body weight at 2 years post-op, and who have been compliant with a prescribed nutrition and exercise program following the procedure.>50% excess body weight loss not achieved at 2 years

Member must be compliant with prescribed program

Revision for mechanical failure: Revision of a primary bariatric procedure for failure due to dilation of the gastric pouch, dilated gastrojejunal stoma, or dilation of the gastrojejunostomy anastomosis is medically necessary if the primary procedure was successful in inducing weight loss prior to the dilation and the member has been compliant with a prescribed nutrition and exercise program.

Band complications: Conversion from an adjustable gastric band to sleeve gastrectomy, RYGB, or BPD/DS is medically necessary for members compliant with prescribed nutrition/exercise when complications cannot be corrected with band manipulation, adjustments or replacement. Replacement of an adjustable band is considered medically necessary if complications (e.g., port leakage, slippage) cannot be corrected.

Complications and concomitant procedures

The following procedures are considered medically necessary when indicated:

Band removal/repair: Removal of a gastric band when recommended by the treating physician, and replacement of an adjustable band when complications cannot be corrected with manipulation or adjustments.

Surgical correction of complications: Surgery to correct complications from bariatric surgery (e.g., obstruction, stricture, erosion, band slippage) and surgery for symptomatic Candy cane syndrome when diagnosis is confirmed by endoscopy or upper GI contrast studies.

Diagnosis confirmation by endoscopy or upper GI contrast studies for Candy cane syndrome

Routine cholecystectomy performed in concert with elective bariatric procedures is considered medically necessary due to the high incidence of gallbladder disease after morbid obesity surgery.

Incidence cited as 28%

Liver biopsy: Routine liver biopsy during bariatric surgery is considered not medically necessary in the absence of signs or symptoms of liver disease (e.g., elevated liver enzymes, hepatomegaly).

Specified covered and not-covered concurrent procedures

Coverage determinations in this excerpt:

Cholecystectomy concurrent with bariatric surgery: Routine cholecystectomy is considered medically necessary when performed in concert with elective bariatric procedures due to a documented high incidence of gallbladder disease after morbid obesity surgery.

Supporting incidence cited as 28%.

Liver biopsy during bariatric surgery: Routine liver biopsy during bariatric surgery is not medically necessary in the absence of signs or symptoms of liver disease (e.g., elevated liver enzymes, enlarged liver).

Include only when clinical signs/symptoms are present.

Experimental / Investigational

The following procedures are considered experimental and investigational (not covered):

Experimental/Investigational procedures: Procedures and techniques listed in the policy are considered experimental and investigational and not covered. Examples include adjunctive omentectomy to bariatric surgery; AspireAssist aspiration therapy; band-over-bypass or band-over-sleeve techniques; various endoscopic techniques and devices including endoscopic outlet reduction (TORe), endoscopic gastrointestinal liners (e.g., EndoBarrier), intragastric balloons, restorative obesity surgery endoluminal (ROSE), transoral gastroplasty, NOTES-related closure/closure devices, loop or mini gastric bypass, laparoscopic gastric plication, open adjustable gastric banding, prophylactic mesh placement for incisional hernia prevention, prophylactic pyloroplasty via botulinum toxin after sleeve, VBLOC (vagus nerve blocking), VBG (except limited circumstances), measurement of serum CRP for complication prediction, and numerous other enumerated procedures in the full list.

Full enumerated list available in document chunks 20–22.

Open or laparoscopic Vertical Banded Gastroplasty (VBG) is addressed specifically in the policy: VBG is considered medically necessary only for members who otherwise meet selection criteria for obesity surgery and who have documented clinical conditions that increase the risk of Roux-en-Y gastric bypass (RYGB). Examples of such increased-risk scenarios include extensive intra-abdominal adhesions from prior major abdominal surgery or trauma, hepatic cirrhosis with elevated liver function tests, inflammatory bowel disease (Crohn’s disease or ulcerative colitis), ASA Class IV systemic disease, or radiation enteritis. Outside of these limited circumstances, the policy states that VBG is considered experimental and investigational.

The policy lists numerous bariatric and endoscopic procedures that are considered experimental and investigational (not covered). Examples include adjunctive omentectomy, AspireAssist aspiration therapy, ‘‘band over bypass’’ or ‘‘band over sleeve’’ revisions, laparoscopic gastric plication (LGCP), laparoscopic single-anastomosis duodeno-ileal bypass with plication, liposuction related to bariatric surgery, loop and mini gastric bypass, and several NOTES or transoral endoscopic techniques.

Endoscopic devices and procedures expressly listed as not covered include endoscopic gastrointestinal liners (e.g., EndoBarrier), intragastric balloons (e.g., Obalon, ReShape systems), endoscopic outlet reduction (TORe), restorative obesity surgery endoluminal (ROSE), transoral gastroplasty/endoscopic sleeve gastroplasty, endoscopic closure or suturing systems (OTSC, Apollo OverStitch, StomaphyX), and other similar endoluminal approaches. The policy also names VBLOC (vagus nerve blocking/Maestro), coated stent use for gastro-jejunal fistula, prophylactic mesh or pyloroplasty via botulinum injection, certain bypass variants (mini/loop), and VBG except in the limited circumstances previously described as examples of procedures considered investigational.

Curative considers routine liver biopsy during bariatric surgery to be not medically necessary when performed in the absence of clinical signs or symptoms of liver disease. Examples of such signs or symptoms include elevated liver enzymes and an enlarged liver (hepatomegaly).

To restate policy guidance for surgical planning and documentation: performing a liver biopsy routinely at the time of bariatric surgery without documented signs or symptoms of liver disease (for example, abnormal liver function tests or hepatomegaly) is considered not medically necessary and may be denied.

Clinical Thresholds and Key Definitions

BMI thresholds and Asian ancestry adjustment

Adult BMI threshold — severe obesityBMI >40 (or >37.5 for persons of Asian ancestry) measured prior to preoperative preparatory program

Adult BMI threshold — with qualifying comorbidityBMI >35 (or >32.5 for persons of Asian ancestry) measured prior to preoperative preparatory program in conjunction with at least one listed severe comorbidity

Adolescent thresholds (context)Adolescents: Class III obesity or Class II with qualifying comorbidity; must have completed bone growth (generally ≥13 girls, ≥15 boys)

Preoperative medication requirement

Required preoperative medicationOne year use of Mounjaro prior to surgery unless there is documented intolerance or a contraindication

Documentation allowance

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior authorization required for bariatric procedures

Obtain prior authorization before elective bariatric surgery; the request must demonstrate medical necessity per the policy selection criteria and that the procedure will be performed at an accredited Bariatric Center by qualified surgeons.

Prior Authorization

Prior authorization for experimental/investigational procedures

Obtain prior authorization for any procedure listed as experimental/investigational; such requests should be expected to be denied for procedures on the policy's exclusion list.

Step Therapy

Preoperative medication and behavioral program required

Document one year of preoperative Mounjaro (unless there is a documented intolerance or contraindication) and completion of a 6–12 month intensive multicomponent behavioral program before approval.

Background and Scope

Bariatric surgical procedures — including Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy, adjustable gastric banding, biliopancreatic diversion with or without duodenal switch (BPD/DS), SADI-S, and SIPS — are therapeutic options for treating severe obesity and many obesity-related comorbidities. These operations are typically performed by surgeons trained in bariatric techniques within accredited comprehensive bariatric programs; preoperative evaluation commonly includes nutritional, behavioral and psychosocial assessments and screening for obstructive sleep apnea as part of preparation for surgery.

Definitions and Procedural List

Medically necessary bariatric procedures

Roux-en-Y Gastric Bypass (RYGB)Open or laparoscopic short- or long-limb RYGB when selection criteria are met

Sleeve GastrectomyOpen or laparoscopic sleeve gastrectomy when selection criteria are met

Biliopancreatic Diversion (BPD) ± Duodenal Switch (DS)Open or laparoscopic BPD with or without duodenal switch when selection criteria are met

Laparoscopic Adjustable Silicone Gastric Banding (LASGB)LASGB when selection criteria are met

Single Anastomosis Duodenal-Ileal Switch (SADI-S) / SIPSOpen or laparoscopic SADI-S and sleeve gastrectomy with single anastomosis duodeno-ileal bypass (SIPS) when selection criteria are met

Intensive multicomponent behavioral intervention — definition

Policy Summary

Payermediviewcurative

PolicyBariatric Surgery Medical Necessity and Preoperative Requirements

Policy CodePolicy MM-PNP-005

Change TypeNo material change

Effective DateMar 22, 2024

Next Review Date

SourceLink

On This Page

One year use of Mounjaro prior to surgery unless documented intolerance/contraindication AND participation in a 6–12 month intensive multicomponent behavioral intervention with documentation (as required for adults).

Program documentation acceptable; same standards as adults

Conversion for GERD: Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass for treatment of symptomatic gastroesophageal reflux disease (GERD) is medically necessary when reflux is documented by abnormal 24‑hour pH monitoring or endoscopically proven esophagitis performed after the sleeve, and symptoms persist despite optimal medical therapy including behavioral modification and at least one month of maximum PPI therapy.1 month maximum PPI trial

When performed primarily for reflux meeting these criteria, conversion is not considered repeat bariatric surgery

Include liver biopsy only when clinical signs/symptoms of liver disease are present

If intolerance/contraindication documented, the one-year Mounjaro requirement may be waived

Applies to adolescents and adultsRequirement specified for both adult and adolescent candidates who otherwise meet criteria

Behavioral program duration and requirements

Program duration requirementParticipation in a 6–12 month intensive multicomponent behavioral intervention prior to surgery

Session minimumProgram must be intensive (12 or more sessions on separate dates) and occur within 2 years prior to surgery

Program components and documentationMust include monthly documented weight history with 5% weight loss, documented dietary and physical activity modification, and psychosocial-behavioral evaluation/sign-off; program records may substitute for medical records for commercial programs

Mounjaro use must be documented for 1 year prior to surgery or a documented intolerance/contraindication.
Behavioral program must be intensive (12+ sessions on separate dates within 2 years prior to surgery) with monthly weight history showing 5% weight loss, dietary and physical activity modification documentation, and psychosocial evaluation/sign-off (or participation in a 6‑month multidisciplinary preparatory regimen).

Note

Other required provider actions (documentation, screening, center evaluation)

Follow all additional provider action items in the policy, including documentation, screening, and center-based evaluation requirements summarized elsewhere in this section.

Documentation Required

Behavioral intervention and psychosocial documentation required

Document participation and compliance in the intensive multicomponent behavioral intervention in the medical record; program records from recognized commercial programs may be used as substitutes.

Records must document monthly detailed weight history with 5% weight loss, dietary modification, physical activity modification, and psychosocial-behavioral evaluation/sign-off.
Programs must be intensive (12+ sessions) and occur within 2 years prior to surgery (may substitute program records such as Noom, Jenny Craig, OptiFast, etc.).

Documentation Required

Document OSA screening using a validated questionnaire

Screen for obstructive sleep apnea using a validated questionnaire and document that screening in the medical record; results do not need to be submitted for review unless requested.

Acceptable tools include ESS, STOP, STOP‑Bang, Berlin, Wisconsin Sleep Questionnaire, or MVAP.
Screening is not required for persons already diagnosed with OSA.

Documentation Required

Adolescent evaluation at accredited bariatric center required

For adolescents, obtain evaluation at or in consultation with a multidisciplinary/adolescent accredited bariatric center and document that bone growth is complete (generally ≥13 years for girls and ≥15 years for boys).

Center should be MBSAQIP‑accredited or demonstrate equivalent program components.
Adolescent preoperative requirements (Mounjaro and behavioral program) must be documented as for adults.

Documentation Required

Document concurrent cholecystectomy when performed with bariatric surgery

When cholecystectomy is performed concurrently with elective bariatric procedures, document that it was performed concurrently to treat symptomatic disease to support medical necessity.

Denial Risk

Denial risk: missing preoperative Mounjaro or behavioral program documentation

Failure to provide documented one‑year Mounjaro use (unless intolerance/contraindication) or lack of documentation of the required intensive behavioral program may result in denial of medical necessity for surgery.

Denial Risk

Denial risk: BMI and comorbidity thresholds must be documented

Ensure the member meets BMI thresholds and documented qualifying comorbidities; failure to meet BMI criteria or lack of required comorbidity documentation (for BMI 35–39.9) risks denial.

Adults: BMI >40 (or >37.5 for persons of Asian ancestry), or BMI >35 (or >32.5 for persons of Asian ancestry) with a listed severe comorbidity.
Adolescents: Class III or Class II with qualifying comorbidity per policy; OSA used as a comorbidity must be confirmed on polysomnography if cited.

Denial Risk

Denial risk: routine liver biopsy without signs/symptoms

Do not perform routine liver biopsy during bariatric surgery unless there are signs or symptoms of liver disease; routine biopsies without clinical indicators may be denied as not medically necessary.

Examples of signs/symptoms include elevated liver enzymes or hepatomegaly.

Denial Risk

Denial risk: experimental/investigational procedures

Claims for procedures enumerated as experimental/investigational in the policy (for example intragastric balloons, endoscopic gastrointestinal liners, VBLOC, various bypass/plication techniques, ROSE, TORe, liposuction related to bariatric surgery, and others) are at high risk for denial.

Refer to the full exclusion list in the policy chunks 20–22 for specific procedures and devices.

DefinitionAn intensive multicomponent behavioral intervention is a program of nutrition, physical activity, and behavioral modification required prior to surgery

Minimum sessions and timingProgram must include 12 or more sessions on separate dates and occur within 2 years prior to surgery (may extend beyond 2 years if final session was within 2 years)

Core program componentsMust document monthly weight history with 5% weight loss, dietary modification, physical activity modification, and psychosocial-behavioral evaluation/sign-off

Signs or symptoms of liver disease

Examples of clinical signs/symptomsElevated liver enzymes

Physical findingEnlarged liver (hepatomegaly)

Policy impactRoutine liver biopsy during bariatric surgery is not medically necessary in the absence of these signs or symptoms