CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Bariatric Surgery / Gastric Bypass Coverage Criteria

Policy governing coverage of digestive system surgical services with emphasis on bariatric procedures (including gastric bypass and adjustable gastric banding) for Neighborhood Health Plan of Rhode Island members and specific benefit packages.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBariatric Surgery / Gastric Bypass Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient hospitalizations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

oneLaparoscopic Adjustable Gastric Banding allowed per lifetime when medically necessary

oneGastric bypass procedure allowed per lifetime

multipleVersion history entries

Coverage Criteria for Bariatric Procedures

Covered Bariatric Procedures with Limits

Covered when ALL of the following benefit and medical necessity conditions are met

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Lifetime limits: One (1) Laparoscopic Adjustable Gastric Banding per lifetime when medical necessity criteria are met; One (1) Gastric Bypass procedure is allowed per lifetime.

Prior procedure requirement: Gastric bypass procedure may be covered if medically necessary after failed laparoscopic procedure.

Coverage limitations: Experimental procedures and non–FDA approved services are not covered except in the treatment of cancer; cosmetic surgery and procedures are not covered; all inpatient hospitalizations require medical review and prior authorization.

Refer to prior authorization requirements for inpatient admissions.

Covered bariatric procedures are limited by lifetime allowances and prior procedure requirements. When medical necessity criteria are met, members are allowed one (1) Laparoscopic Adjustable Gastric Banding per lifetime and one (1) Gastric Bypass procedure per lifetime. Additionally, a gastric bypass procedure may be covered if medically necessary after a failed laparoscopic procedure (surgical step requirement). All inpatient hospitalizations for these services require medical review and prior authorization.

Coverage exclusions and limitations include experimental procedures and non–FDA approved services, which are not covered except in the treatment of cancer. Cosmetic surgery and procedures are not covered. Extended Family Planning (EFP) members are excluded from comprehensive benefits and do not have the full benefit package for these services. All inpatient admissions require prior authorization and medical review.

Provider Requirements and Authorization

Prior Authorization

Inpatient prior authorization required

All inpatient hospitalizations require medical review and prior authorization.

Step Therapy

Surgical step requirement

Gastric bypass may be covered only if it is medically necessary after a failed laparoscopic procedure.

Documentation Required

Prior authorization and documentation

All inpatient hospitalizations require medical review and prior authorization. Providers should also refer to related benefit coverage summaries (e.g., Transplant, Dialysis, Outpatient Surgery) for additional documentation and benefit-specific requirements.

Denial Risk

Coverage exclusions that can trigger denial

Experimental procedures and non‑FDA approved services are not covered (except in the treatment of cancer), and cosmetic surgery and procedures are not covered; claims for these services may be denied.

Exceptions: treatment of cancer for non‑FDA approved services is covered per policy.

Background

Digestive system services encompass surgical procedures for treatment of obesity and other digestive conditions. Bariatric procedures are subject to member benefit limitations and clinical medical policy guidance, including restrictions on experimental or non–FDA approved services, coverage limited to specified lifetime procedures, and requirements for prior authorization for all inpatient hospitalizations.

Definitions

Digestive system services — key facts

DefinitionDigestive system services include a broad range of surgical services and procedures involving the digestive system.

Covered benefit nameDigestive System Services

Applicable benefit packagesRIte Care; Children with Special Health Care Needs; Substitute Care; Rhody Health Partners; Rhody Health Options Phase One

CMP publishedYes

Experimental/Investigational noteExperimental Investigational Services referenced (see exclusions for specifics).