CurrentmhnPolicy CP.MP.37

Clinical Policy: Bariatric Surgery

Defines medical necessity, preoperative requirements, repeat/conversion surgery criteria, investigational procedures, and procedures considered not medically necessary for bariatric surgery for members/enrollees served by Centene-affiliated health plans; includes coding implications and lists of CPT/HCPCS codes that support or do not support medical necessity (partial list in this part).

Policy Summary

Payermhn

PolicyClinical Policy: Bariatric Surgery

Policy CodePolicy CP.MP.37

Change TypeMultiple revisions (criteria, coding, procedures)

Effective Date

Next Review Date

Key ActionObtain and document within 6 months: medical evaluation and clearance from a non-surgeon physician (preferably PCP); nutritional evaluation; and age-appropriate psychiatry/psychology consultation confirming suitability and management of mental health disorders.

POLICY UPDATE CHANGES

Added BMI criteria for Asian ethnicity to I.A.1 and updated BMI thresholds; moved and reclassified Type 2 diabetes as absolute comorbidity for certain lower-BMI indications.

Added SADI/SADI-S to indications and procedure lists; added CPT 43999 for SADI-S.

Changed GFR threshold from <30 to <60 mL/min/1.73m2 in preoperative criteria.

Updated comorbidity lists: added CKD, infertility, PCOS, atrial fibrillation, heart failure; removed high risk for type 2 DM and severe urinary incontinence.

Removed Helicobacter pylori screening and removed monthly nutritional counseling requirement.

Changed medical clearance phrasing to require evaluation by a physician other than the surgeon.

Added CPT codes 43290, 43291, and 43632 to not medically necessary table and removed CPT codes 0312T-0317T.

Multiple revision log entries through 2020-2024 reflect iterative updates to BMI thresholds, comorbidity lists, preoperative testing requirements, and lists of investigational procedures.

Removed requirement for bariatric surgery center and adjusted preoperative testing requirements (e.g., ECG, chest x-ray, PSG) and substance-abuse screening criteria in various revisions.

Added gastric reduction duodenal switch and SADI-S procedure references and incorporated SADI-S discussion in background and rationale.

Corrected policy statement I. to require requirements in I.A and I.B be met (not I.A-C).

>=1BMI thresholds defined

15+Investigational/Not medically necessary procedures

20+CPT/HCPCS codes referenced

1New CPT added for SADI-S

3CPT codes added to not medically necessary

Coverage Summary

This policy defines medical necessity and coverage criteria for bariatric surgery for members/enrollees of Centene-affiliated health plans, including initial and repeat (conversion/revision) procedures, preoperative requirements, lists of investigational procedures, and procedures considered not medically necessary. Key covered primary procedures explicitly include LAGB, LSG (sleeve gastrectomy), laparoscopic RYGB, BPD-DS/BPD-GRDS, and the single-anastomosis duodenoileal bypass family (SADI/SADI-S) which were added to the description and indications. The policy applies ethnicity-specific BMI thresholds (e.g., ≥ 32.5 kg/m2 for South/Southeast/East Asian adults or ≥ 35 kg/m2 for other adults for primary procedures) and lower-BMI pathways with listed comorbidities for consideration. The coverage stance is mixed: many established procedures are covered when criteria are met, some procedures are listed as investigational/insufficient evidence, and a subset are considered not medically necessary.

Selected thresholds

Adult BMI (general ethnicities)≥ 35 kg/m2

Adult BMI (South/Southeast/East Asian)≥ 32.5 kg/m2

Lower-BMI with comorbidity (general ethnicities)≥ 30 and < 35 kg/m2

Adolescent BMI threshold≥ 35 kg/m2 or 120% of the 95th percentile (whichever is lower)

GFR cutoff for preoperative criteria< 60 mL/min/1.73m2

Time since prior bariatric surgery for revision≥ 2 years

Minimum interval after LAGB removal before subsequent procedure≥ 2 months

Insufficient initial weight loss definition< 50% excess body weight loss

Recent myocardial infarction interval (exclusion/consideration)within the past 60 days

Medical-Necessity Criteria

Initial bariatric surgery - Medical necessity

Bariatric surgery is medically necessary when ALL of the following in sections A and B are met:

ALL of the following

A. Medical history
- Age and BMI (meet criteria in a or b)
  - a. Age > 18 and one of the following (i or ii)
    i or ii
    i. BMI ≥ 32.5 kg/m2 for South Asian, Southeast Asian, and East Asian adults or ≥ 35 kg/m2 for all other ethnicities when LAGB, LSG, laparoscopic RYGB, SADI/SADI-S, or BPD-DS/BPD-GRDS is requested
    ii
    Comorbidities (at least one)

Investigational / Not Medically Necessary Procedures

Procedures — Indications and Status Updates (Selected)

Procedural and coding status changes in the revision log and policy: SADI-S (single-anastomosis duodenoileal bypass with sleeve gastrectomy) was added to the procedure description and to Criteria I.A age/BMI indications and is listed as medically necessary when used for conversion from LAGB; SADI was removed from the investigational list/background. One-anastomosis (mini) gastric bypass was removed from the investigational list as duplicative. For coding, CPT 43999 (unlisted procedure, stomach) was added for SADI-S. Additionally, multiple CPT codes (including 43290, 43291, and 43632) were added to the not medically necessary table, and other CPT updates/ deletions are reflected in the coding tables.

I.A. Indications - Adults and Pediatrics (selected modifications captured in this part)

Covered when ALL of the following (as amended) are met for the specified age/BMI groups and comorbidity lists

I.A. Indications - selected modifications

Adults age ≥18: expanded procedures
- SADI / SADI-S added to description and indications
Asian-specific BMI categories (selected change)

Coding

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 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)
43843	Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty
43845	Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch)

1–10 of 18

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 electrodes, antrum
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	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

Added CPT codes to not medically necessary tableCPTNot Covered

43290
43291
43632

Added CPT for SADI-S procedureCPTCovered

43999

Added for SADI-S procedure (single-anastomosis duodenoileal bypass with sleeve gastrectomy)

Removed/deleted CPT codesCPT

0312T	deleted
0313T	deleted
0314T	deleted
0315T	deleted
0316T	deleted
0317T	deleted

Provider Actions

Documentation Required

Preoperative medical clearance and evaluations

Obtain and document within 6 months a medical evaluation and clearance from a physician other than the operating surgeon (preferably the member's primary care physician); nutritional evaluation by a qualified provider; and an age-appropriate psychiatry/psychology consultation confirming the candidate is appropriate and mental health disorders are adequately managed.

Medical evaluation from a non-surgeon physician (preferably PCP) — recommendation and clearance
Nutritional evaluation by a qualified provider (physician, PA, ARNP, or RD)
Age-appropriate psychiatry/psychology consultation confirming suitability and management of mental health disorders
All items documented within 6 months of scheduled surgery

Documentation Required

Background & Evidence

Background rationale: Bariatric surgery is the only proven method for long-term weight control in clinically severe obesity because nonoperative methods typically fail to sustain weight loss. The policy describes restrictive and malabsorptive procedures and notes trends favoring laparoscopic sleeve gastrectomy (LSG) as the most commonly performed procedure due to lower complication and nutritional deficiency rates while maintaining comparable weight loss and metabolic outcomes. Professional society positions are summarized: the ASMBS endorses use of SADI-S with caution and calls for more long-term outcome data and nutritional guidance; IFSO views SADI-S as safe and reproducible with meaningful medium- to long-term weight loss but notes limited data beyond six years and recommends registry participation and RCTs; NICE similarly encourages further research and recommends special arrangements for governance and audit. The background emphasizes the need for multidisciplinary patient selection, long-term follow-up, and ongoing nutritional monitoring given potential nutritional deficiencies and long-term safety concerns.

Source	Summary
ASMBS guideline summary
Recommends metabolic and bariatric surgery for patients with BMI ≥ 35 kg/m2 regardless of comorbidities; considers surgery for BMI 30–34.9 kg/m2 after failure of nonsurgical methods; for patients with type II diabetes, surgery recommended for BMI ≥ 30 kg/m2.
IFSO 2024 statement
States SADI-S is safe and reproducible with low rates of early and late complications and provides significant sustained weight loss over medium- to long-term follow-up up to five years, but data beyond six years remain limited and further long-term outcomes and RCTs are encouraged.
References updated
Multiple guideline and literature references supporting updates through 2024–2025 are cited (ASMBS, IFSO, NICE, UpToDate, Cochrane and other studies).

Medicare Determinations

Name	Number	Effective Date	Type
Bariatric surgery for treatment of co-morbid conditions related to morbid obesity
100.1
2013-09-24
NCD

Revision History

10/20 (rev notes)revised

Added BMI criteria for Asian ethnicity to I.A.1 (BMI ≥ 32.5 kg/m2 for South/Southeast/East Asian adults or ≥ 35 kg/m2 for others; and lower-BMI ranges for comorbidity-driven indications). is_material

03/23 (rev notes)revised

Moved Type 2 diabetes mellitus to an absolute comorbidity within I.A.1.a.ii.b) and updated BMI thresholds/related language for lower-BMI indications. is_material

03/24 (annual review)revised

Updated comorbidity list: removed 'high risk for type 2 DM' and 'severe urinary incontinence'; changed 'poorly controlled hypertension' to 'hypertension'; added chronic kidney disease, infertility, and polycystic ovarian syndrome; added atrial fibrillation and heart failure to adult comorbidity list. is_material

Policy Summary

Payermhn

PolicyClinical Policy: Bariatric Surgery

Policy CodePolicy CP.MP.37

Change TypeMultiple revisions (criteria, coding, procedures)

Effective Date

Next Review Date

On This Page

Type 2 diabetes mellitus (DM)
Hypertension
Dyslipidemia
Obstructive sleep apnea
Obesity-hypoventilation syndrome/Pickwickian syndrome
Nonalcoholic fatty liver disease or nonalcoholic steatohepatitis
Pseudotumor cerebri
Coronary artery disease
Gastroesophageal reflux disease
Asthma
Venous stasis disease
Bone and joint diseases
Disqualification from other specialty surgeries due to obesity (e.g., joint arthroplasty, abdominal wall hernia repair, or organ transplantation)
Chronic kidney disease
Infertility
Polycystic ovarian syndrome
Atrial fibrillation
Heart failure

b. Age < 18 years: LSG or laparoscopic RYGB requested, and BMI ≥ 35 kg/m2 or 120% of the 95th percentile (whichever is lower)

B. Preoperative evaluation and medical clearance

1. Medical evaluation from a physician other than the surgeon (preferably PCP) including recommendation and medical clearance for the requested procedure
2. Nutritional evaluation by a qualified provider (physician, PA, ARNP, or RD)
3. Age-appropriate psychiatry/psychology consultation stating candidate is appropriate and mental health disorders are adequately managed

For South Asian, Southeast Asian, and East Asian adults: BMI ≥ 27.5 and < 32.5 kg/m2 (and other listed criteria) and for some groups ≥ 30 and < 35 kg/m2 — indication I.A.1.a.ii.a) removed for continued obesity despite prior attempts at weight loss

Pediatric/Adolescent indications (selected changes)

Removed Criterion I.A.1.b.i regarding BMI ≥ 40 kg/m2 for age <18 years
Removed severe comorbidities listed in Criteria I.A.1.b.ii for age <18 years with BMI ≥ 35 kg/m2
Added pediatric indications: atrial fibrillation and heart failure added to comorbidity list

Comorbidity list updates (selected)

Removed high risk for type 2 diabetes as a distinct criterion
Changed poorly controlled hypertension to hypertension
Removed severe urinary incontinence
Updated language to 'bone and joint diseases'
Added chronic kidney disease
Added infertility
Added polycystic ovarian syndrome

Documentation for repeat/conversion surgery

For repeat or conversion bariatric procedures, include documentation of the prior bariatric procedure date, percent excess body weight loss from the initial procedure, documented compliance with previously prescribed postoperative nutrition and exercise program, a clinical explanation from the provider of why the initial procedure failed, and documentation of the required interval since the prior surgery (generally ≥ 2 years, or ≥ 2 months after removal of an eroded LAGB).

Date of prior bariatric procedure
Percent excess weight loss from the initial procedure (< 50% meets criterion for revision)
Documented compliance with prior postoperative nutrition and exercise program
Clinical explanation of circumstances/reason the procedure failed
Interval since prior surgery: ≥ 2 years (or ≥ 2 months after eroded LAGB removal)

Prior Authorization

Medical necessity criteria must be met for coverage

Include all applicable medical necessity requirements in the prior authorization request: the member must meet the policy's medical history, age/BMI (including ethnicity-specific BMI thresholds where applicable), and preoperative evaluation criteria. Ensure authorization documents reference the I.A and I.B criteria required for coverage.

Include ethnicity-specific BMI thresholds (e.g., South/Southeast/East Asian BMI cutoffs) when applicable
Confirm all I.A (indications/age/BMI/comorbidities) and I.B (preoperative evaluations/clearance) requirements are met and documented

Billing Rule

Use appropriate CPT/HCPCS codes

Report appropriate CPT and HCPCS codes that support medical necessity for covered bariatric procedures and avoid billing codes listed as not supporting medical necessity. Inclusion or exclusion of codes in this policy does not guarantee coverage — providers must reference current coding guidance prior to claim submission.

Use codes from the 'supporting medical necessity' group for covered procedures
Do not use codes listed in the 'do not support medical necessity' group for covered bariatric procedures
Inclusion/exclusion of a code in this policy is informational and does not guarantee payment; verify current coding guidance

Documentation Required

Medical evaluation source

Obtain and document a medical evaluation from a physician other than the operating surgeon (preferably the patient's primary care physician) as part of preoperative clearance.

Medical evaluation must be from a non-surgeon physician (preferably PCP)
Evaluation should include recommendation for bariatric surgery and medical clearance

Documentation Required

GI evaluation and treatment

Document gastrointestinal (GI) screening and evaluation for clinically significant GI symptoms and document any needed treatment prior to bariatric surgery.

GI screening and evaluation for clinically significant symptoms
Documentation that necessary GI treatment was completed prior to surgery

Documentation Required

Preoperative renal function

Document preoperative renal function, including glomerular filtration rate (GFR). The policy specifies GFR < 60 mL/min/1.73 m2 as a relevant threshold in the preoperative criteria.

Document measured or estimated GFR
Note that GFR < 60 mL/min/1.73 m2 is the policy-specified cutoff of concern

Documentation Required

Nutritional supplementation

Document required nutritional supplementation and counseling, including specific supplementation for thiamine, calcium, and fat‑soluble vitamins as outlined in the preoperative/nutritional requirements.

Document plans for thiamine supplementation
Document plans for calcium supplementation
Document plans for fat‑soluble vitamin supplementation (A, D, E, K) per I.B.4

Billing Rule

CPT coding for SADI-S

When performing a SADI‑S procedure, report CPT code 43999 (unlisted procedure, stomach) as specified in the policy updates.

codes: 43999

Billing Rule

Not medically necessary codes

Do not cover services billed with the CPT codes that the policy lists as not supporting medical necessity. The policy added the following CPT codes to the not medically necessary table and instructs they should not be used for covered bariatric indications.

codes: 43290, 43291, 43632
Services billed with these CPT codes are listed as not medically necessary per the policy

06/22 - 03/23 (rev notes)revised

Coding updates: removed/deleted CPT 0312T–0317T and added CPT codes 43290, 43291, and 43632 to not medically necessary table. is_material

03/24 - 02/25 (rev notes)revised

Preoperative criteria consolidated and modified: replaced prior PCP/specialist clearance language with requirement for medical evaluation from a physician other than the surgeon; clarified glycemic evaluation to include A1c and fasting glucose; removed monthly nutritional counseling requirement; specified GI screening and treatment for significant GI symptoms; removed Helicobacter pylori screening. is_material

03/24 - 06/21 (rev notes)revised

Cardio/pulmonary and testing requirements modified: removed routine ECG/chest x-ray requirements except for high risk, limited polysomnography to when OSA screening positive, removed 1-year abstinence and routine urine drug screen if history of abuse; added note for medical director review if A1C ≥8. is_material

06/21 - 09/25 (rev notes)addedLatest

SADI-S (single-anastomosis duodenoileal bypass with sleeve gastrectomy) added to procedure lists and to I.A.1 indications (I.A.1.a.i and I.A.1.a.ii); SADI-S listed as medically necessary following conversion from LAGB; SADI/SADI-S removed from investigational list; CPT 43999 added for SADI-S. is_material

03/24 - 02/25 (rev notes)revised

GFR cutoff in preoperative criteria changed from <30 to <60 mL/min/1.73m2 (Criterion I.B.1.b.iv). is_material

04/25 (administrative)clarified

Administrative correction: policy statement I. clarified to require requirements in I.A and I.B be met (not I.A-C).