Modifiedmeridian_health_plan_of_michiganPolicy MI.CP.MP.37

Bariatric Surgery (Clinical Policy)

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Defines medical necessity criteria, covered and not-covered bariatric surgical procedures, coding guidance, and applicability for Michigan Medicaid members of Meridian Health Plan of Michigan.

Policy Summary

PayerMeridian Health Plan of Michigan

PolicyBariatric Surgery (Clinical Policy)

Policy CodePolicy MI.CP.MP.37

Change TypeComorbidity list updated (adult editspediatric addition)

Effective Date

Next Review Date

Key ActionObtain prior authorization for removal, revision, or replacement of adjustable gastric devices and for associated reconstructive procedures.

SourceLink

POLICY UPDATE CHANGES

Comorbid conditions for adults were updated (removed 'poorly controlled' hypertension, removed severe urinary incontinence, removed idiopathic intracranial hypertension; added chronic kidney disease and polycystic ovarian disease).

For patients under 18 years, nonalcoholic fatty liver disease was added to the list of qualifying severe comorbidities.

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

Modifiedmeridian_health_plan_of_michiganPolicy MI.CP.MP.37

Bariatric Surgery (Clinical Policy)

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Sign up for meridian_health_plan_of_michigan Policy MI.CP.MP.37 alerts

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Defines medical necessity criteria, covered and not-covered bariatric surgical procedures, coding guidance, and applicability for Michigan Medicaid members of Meridian Health Plan of Michigan.

Policy Summary

PayerMeridian Health Plan of Michigan

PolicyBariatric Surgery (Clinical Policy)

Policy CodePolicy MI.CP.MP.37

Change TypeComorbidity list updated (adult editspediatric addition)

Effective Date

Next Review Date

Key ActionObtain prior authorization for removal, revision, or replacement of adjustable gastric devices and for associated reconstructive procedures.

SourceLink

POLICY UPDATE CHANGES

For patients under 18 years, nonalcoholic fatty liver disease was added to the list of qualifying severe comorbidities.

≥35Adult BMI ≥ threshold

30–34.9Adult BMI range if comorbidity

MI MedicaidApplies to

≥40Pediatric severe criterion

PresentLegal disclaimers

Medical Necessity and Exclusions for Bariatric Surgery

Medical necessity criteria (by age/BMI/comorbidity)

Coverage is medically necessary when ALL of the following age/BMI/comorbidity combinations are met as specified:

Primary policy statement: It is the policy of Meridian Health that bariatric surgery is medically necessary when the criteria in A (1, 2, or 3) and 4 are met.

From policy criteria section

A. Age and BMI - Adults and adolescents: One of the following age/BMI paths must be met.

Subnodes define adult and pediatric paths

A.1 Adults (Age > 18) - Path 1: Age > 18 and one of the following: a) BMI ≥ 35 kg/m² regardless of the presence or absence of comorbidities; or b) BMI ≥ 30 kg/m² and < 35 kg/m² and at least one of the listed comorbid conditions.BMI thresholds as stated

Comorbid conditions listed in policy

A.2 Adults (Age > 18) - Excess abdominal obesity path: Age > 18 with excess abdominal obesity if medically indicated and one of: a) BMI ≥ 32.5 kg/m² and ≤ 34.9 kg/m² regardless of comorbidities; or b) BMI ≥ 27.5 kg/m² and ≤ 32.4 kg/m² with at least one of the listed comorbid conditions.BMI ranges as stated

Comorbid conditions list mirrors A.1 with specific items

A.3 Pediatric patients (Age < 18): LSG or laparoscopic RYGB is requested and one of the following: a) BMI ≥ 40 kg/m² or ≥ 140% of the 95th percentile (whichever is lower); or b) BMI ≥ 35 kg/m² and ≤ 39.9 kg/m² or ≥ 120% of the 95th percentile (whichever is lower) with at least one severe comorbidity listed below that is uncontrolled with lifestyle or pharmacotherapy.Pediatric BMI thresholds as stated

Severe comorbidities enumerated in policy

4. Comorbid conditions list (adult and pediatric): Includes: Type 2 diabetes; high risk for type 2 diabetes (insulin resistance, prediabetes, metabolic syndrome); hypertension; dyslipidemia; obstructive sleep apnea; obesity-hypoventilation syndrome/Pickwickian syndrome; nonalcoholic fatty liver disease/nonalcoholic steatohepatitis; pseudotumor cerebri; coronary artery disease; gastroesophageal reflux disease; asthma; venous stasis disease; bone and joint disease; disqualification from other specialty surgeries due to obesity (e.g., joint arthroplasty, abdominal wall hernia repair, organ transplantation); chronic kidney disease; polycystic ovarian disease; atrial fibrillation; heart failure. Pediatric severe comorbidities also include Blount's disease and slipped capital femoral epiphysis (SCFE), among others listed in the policy.

Full lists in policy chunks 4-6

Not medically necessary / investigational

The following procedures are considered not medically necessary or investigational and are not covered:

Not medically necessary - explicitly listed: Biliopancreatic diversion (Scopinaro procedure); jejunoileal bypass (jejuno-colic bypass); Vertical Banded Gastroplasty (VBG); gastric pacing/gastric electrical stimulation; gastric wrapping.

Chunk 6, Section II

Investigational / inadequate evidence - not covered: Distal (very long limb) gastric bypass; Loop (Mini) Gastric Bypass; laparoscopic re-sleeve gastrectomy (LRSG); Fobi pouch; laparoscopic greater curvature plication (gastric imbrication); LAP-BAND when BMI 30–35 (with or without comorbidities); stomach aspiration therapy (e.g., AspireAssist); endoscopic suture revisions post bariatric surgery; single anastomosis duodenoileal bypass (SADI); gastric plication/endoluminal vertical gastroplasty; endoscopic gastrointestinal bypass devices (EGIBD); one-anastomosis gastric bypass; endoscopic sleeve gastroplasty; transoral endoscopic surgery; vagus nerve blocking (e.g., Maestro); gastric balloon devices (e.g., ReShape Duo, Orbera, Obalon).

Chunk 7, Section III

Specific bariatric surgical procedures listed in Sections II and III of this policy are designated as not medically necessary or investigational/experimental and therefore are excluded from coverage.

Associated reconstructive procedures directly attributable to weight loss surgery (for example, panniculectomy) are not automatically included with bariatric procedure approval and require a separate prior authorization. Removal, revision, or replacement of adjustable gastric restrictive devices and related subcutaneous port procedures are reviewed separately (InterQual® criteria may be applied).

Coverage for services described in this clinical policy is subject to the member's plan documents and all applicable Health Plan administrative policies and procedures. Benefits, limitations, exclusions, and the administration of coverage are governed by the member's evidence of coverage, certificate of coverage, policy or contract, and by applicable state and federal laws and regulations.

Procedures explicitly listed as not medically necessary in Section II include: biliopancreatic diversion (Scopinaro), jejunoileal bypass, vertical banded gastroplasty, gastric pacing/gastric electrical stimulation, and gastric wrapping.

Section III lists additional procedures deemed investigational/experimental and therefore not covered, including but not limited to: distal (very long limb) gastric bypass, loop/mini-gastric bypass, laparoscopic re-sleeve gastrectomy, Fobi pouch, gastric imbrication (greater curvature plication), LAP-BAND for BMI 30–35, AspireAssist/stomach aspiration therapy, endoscopic sleeve gastroplasty, endoscopic gastrointestinal bypass devices, one-anastomosis gastric bypass, vagus nerve blocking, and gastric balloons (see policy Section III for full enumeration).

Procedure and Diagnosis Codes

CPT codes that support medical necessityCPTCovered

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.
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.
43774	Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device (separate procedure).
43775	Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy).
43843	Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than sleeve gastrectomy.
43845	Vertical-banded gastroplasty (listed among codes).

1–10 of 17

1/2

CPT codes that do not support medical necessityCPTNot Covered

43290	Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon.
43291	Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s).
43632	Gastrectomy, partial, distal; with gastrojejunostomy.
43647	Laparoscopy, surgical; implantation or replacement of gastric neurostimulator.
43648	Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum.
43842	Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty.
43847	Banded gastroplasty / gastric restrictive procedure with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption.
43881	Implantation or replacement of gastric neurostimulator electrodes, antrum, open.
43882	Revision or removal of gastric neurostimulator electrodes, antrum, open.
64590	Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling.

1–10 of 11

1/2

HCPCS codes that support medical necessityHCPCSCovered

S2083

Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline.

ICD-10 codesICD-10

ICD-10-CM Code N/A

Document lists ICD-10 section but specific diagnosis codes are not provided in this portion of the policy.

Adult BMI thresholds

Primary adult criterionAge > 18 and BMI ≥ 35 kg/m² (covered regardless of comorbidities)

Adult with lower BMI — excess abdominal obesity path AAge > 18 and BMI ≥ 32.5 kg/m² and ≤ 34.9 kg/m² (covered regardless of comorbidities)

Adult with lower BMI — excess abdominal obesity path BAge > 18 and BMI ≥ 27.5 kg/m² and ≤ 32.4 kg/m² with at least one listed comorbid condition (see policy for full comorbidity list)

Adult BMI range qualifying with ≥1 comorbidityBMI 30.0–34.9 kg/m² with at least one listed comorbidity (policy lists comorbid conditions that qualify)

Pediatric BMI thresholds (age <18)

Prior Authorization, Documentation, and Operational Guidance

Prior Authorization

Prior authorization required for device procedures and reconstructive surgeries

Prior authorization is required for review of removal, revision, and replacement of adjustable gastric restrictive devices and subcutaneous port components; associated reconstructive procedures (e.g., panniculectomy) also require a separate prior authorization and are not automatically covered.

Removal, revision, replacement and repeat procedures of adjustable gastric restrictive devices and subcutaneous port components are reviewed with InterQual criteria.
Obtain a separate PA for associated reconstructive procedures such as panniculectomy; these are not automatically covered.

Note

Policy is a medical necessity guide — follow Health Plan PA procedures

This clinical policy is a guide to medical necessity to assist coverage decisions; providers must follow the Health Plan's prior authorization procedures and applicable Michigan Medicaid rules when requesting coverage.

Follow the Health Plan's PA process and Michigan Medicaid Fee Schedule for codes under review.

Background on Bariatric Surgery

Bariatric surgery encompasses restrictive procedures that reduce stomach capacity (for example, laparoscopic adjustable gastric banding and sleeve gastrectomy) and malabsorptive procedures that bypass portions of the stomach and/or small intestine (for example, biliopancreatic diversion/duodenal switch or Roux-en-Y gastric bypass). The overall purpose is to produce sustained weight loss and improve obesity-related comorbidities; specific procedure selection depends on patient age, BMI, and presence of qualifying comorbid conditions as defined in this policy.

Key Definitions

Body mass index (BMI) — definition and limitations

BMI definitionBody mass index (BMI) is a measure of body fat based on height and weight used for adults; it is an approximation of adiposity and a basis for obesity risk classifications.

Limitation — does not account for individual factorsBMI does not account for sex, age, ethnicity, or fat distribution; individuals with similar BMI may have different metabolic risk based on fat distribution.

Population-specific adjustment — Asian populationsIn Asian populations, obesity-related risk occurs at lower BMI; BMI risk zones may be adjusted (e.g., defining obesity at BMI 25–27.5 kg/m²) and access to metabolic/bariatric surgery should not be denied solely on traditional thresholds.

Policy Summary

PayerMeridian Health Plan of Michigan

PolicyBariatric Surgery (Clinical Policy)

Policy CodePolicy MI.CP.MP.37

Change TypeComorbidity list updated (adult editspediatric addition)

Effective Date

Next Review Date

Key ActionObtain prior authorization for removal, revision, or replacement of adjustable gastric devices and for associated reconstructive procedures.

SourceLink

On This Page

Primary pediatric surgical eligibility

Age < 18 years and procedure requested is LSG or laparoscopic RYGB

Severe obesity thresholdBMI ≥ 40 kg/m² or ≥140% of the 95th percentile (whichever is lower)

Moderate pediatric obesity with comorbidityBMI ≥ 35 kg/m² and ≤ 39.9 kg/m² or ≥120% of the 95th percentile (whichever is lower) with ≥1 severe comorbidity uncontrolled by lifestyle or pharmacotherapy

Note on comorbiditiesSee policy for the enumerated severe comorbidities that qualify pediatric patients (includes conditions such as type 2 diabetes, NAFLD/NASH, orthopedic complications, etc.)

If there is a discrepancy between this policy and the Michigan Medicaid Provider Manual, the Medicaid Provider Manual governs.

Step Therapy

Preoperative weight loss regimen not mandatory

Mandatory participation in a preoperative weight loss regimen prior to weight loss surgery is not required.

Preoperative weight loss programs may be used at the provider's discretion but are not a plan requirement for coverage.

Documentation Required

Follow PA, documentation, and claims submission requirements

Providers must follow established prior authorization, documentation, and coding requirements when submitting requests and claims; consult the policy and Health Plan administrative processes for exact submission expectations.

Coverage decisions are subject to the terms, conditions, exclusions and limitations of the member's coverage documents and applicable Health Plan administrative policies.
This clinical policy does not guarantee payment; follow plan-specific administrative policies and state/federal requirements when submitting claims.

Prior Authorization

Device revisions and reconstructive procedures reviewed with InterQual; PA and fee-schedule rules apply

Removal, revision, replacement and repeat procedures of adjustable gastric restrictive devices and subcutaneous port components are reviewed using InterQual criteria; associated reconstructive procedures require separate PA and eligibility is contingent on Medicaid fee schedule inclusion.

InterQual criteria will be used to review device revision/removal/replacement and repeat procedures.
Ensure requested CPT/HCPCS codes are on the Michigan Medicaid Fee Schedule for coverage consideration.

Documentation Required

Documentation and claims guidance — follow coverage documents and administrative policies

Providers must follow the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract) and Health Plan administrative policies when submitting claims; the clinical policy alone does not guarantee payment.

Claims and documentation must comply with plan terms, exclusions, limitations, and applicable state and federal requirements.
Providers retain responsibility for submitting required medical records and justification to support medical necessity and PA requests.

Denial Risk

Not covered — listed procedures are investigational or not medically necessary

The procedures listed as 'not medically necessary' or 'investigational/experimental' (including biliopancreatic diversion/Scopinaro, jejunoileal bypass, vertical banded gastroplasty, gastric electrical stimulation, loop/mini-gastric bypass, endoscopic sleeve gastroplasty, gastric balloons, AspireAssist, and others) are not covered and will be denial triggers.

Do not submit PA requests for procedures explicitly listed as not medically necessary or investigational; these are excluded from coverage.
Associated coverage denials may occur if billed codes correspond to excluded procedures.

Denial Risk

Coverage subject to plan terms — risk of denial if requirements not met

Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the member's coverage documents and applicable Health Plan administrative policies and procedures; discrepancies are governed by law and regulation and may result in denial if requirements are not met.

Verify member eligibility and benefits, and ensure requested services meet policy criteria and administrative requirements to reduce denial risk.
The clinical policy is not a contract and does not override coverage documents or legal/regulatory requirements.