CurrentOklahoma Health Care AuthorityPolicy N/A

Bariatric Surgery Coverage Criteria

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This guideline establishes OHCA medical-necessity, provider, program, evaluation, prior-authorization, and continued-coverage requirements for bariatric surgery. It applies to members ages 15 through 65 who are being evaluated for, undergoing, or receiving follow-up care related to bariatric surgery.

Policy Summary

PayerOklahoma Health Care Authority

PolicyBariatric Surgery Coverage Criteria

Policy CodePolicy N/A

Change TypeRevision of Existing Criteria

Effective DateSeptember 7, 2023

Next Review DateAugust 2026

Key ActionObtain prior authorization for every bariatric surgery procedure, including procedures billed with unlisted procedure codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15–65Eligible member age range

All

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CurrentOklahoma Health Care AuthorityPolicy N/A

Bariatric Surgery Coverage Criteria

Customize your policy alerts

Sign up for all Oklahoma Health Care Authority policy alerts

Know when Oklahoma Health Care Authority releases new policies or updates existing guidance.

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Policy Summary

PayerOklahoma Health Care Authority

PolicyBariatric Surgery Coverage Criteria

Policy CodePolicy N/A

Change TypeRevision of Existing Criteria

Effective DateSeptember 7, 2023

Next Review DateAugust 2026

Key ActionObtain prior authorization for every bariatric surgery procedure, including procedures billed with unlisted procedure codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15–65Eligible member age range

All

Procedures requiring prior authorization

2Prior authorization phases

6 monthsRequired smoking cessation

8 weeksGERD treatment duration

Bariatric Surgery Coverage Criteria

Provider and Program Requirements

Covered when the bariatric provider, facility, and program meet all applicable requirements below.

ALL of the following

Provider accreditation pathway
- Provider is certified by the American College of Surgeons (ACS) Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) as a Comprehensive Bariatric Surgery Center.
- The surgeon and facility currently participate in a comprehensive multidisciplinary bariatric surgery quality-assurance program and clinical outcomes assessment review as a pathway to accreditation.
Bariatric surgeon has fellowship training in bariatric surgery, is a fellow of the American Society of Metabolic and Bariatric Surgery (ASMBS), or is an MBSAQIP-verified surgeon.
Bariatric facility and providers are contracted with OHCA and have a demonstrated record of quality assurance.
Providers provide OHCA proof of the required certifications annually.
Bariatric program requirements
- Program demonstrates a long-term commitment and sustainable infrastructure for continuity of pre-operative care, post-operative care, and long-term follow-up for bariatric patients in Oklahoma, regardless of where the index surgery occurred.
- Surgeons and programs that opt in knowingly participate in the OHCA system and agree to help care for Oklahoma post-bariatric surgery patients when requested by OHCA.
- Available services and infrastructure
  - Programmatic commitment to long-term care of bariatric patients.
  - Surgical expertise in minimally invasive and bariatric surgery.
  - Comprehensive medical care before surgery.

Qualifying Obesity-Related Comorbidities

Qualifying obesity-related comorbidities include the following conditions and clinical pathways.

ANY of the following

Diabetes mellitus.
Degenerative joint disease of a major weight-bearing joint to an extent that the member would be a candidate for joint replacement surgery if weight loss is achieved.
Degenerative disc or spine disease of significant nature producing clinical symptoms.
Hypertension.
Dyslipidemia.
Coronary artery disease (CAD), including history of stent, myocardial infarction (MI), or cerebrovascular accident (CVA).

Two-Phase Prior Authorization Criteria

Bariatric surgery prior authorization is a two-phase process. Phase I evaluates motivation, knowledge, and physical, mental, and emotional suitability; Phase II confirms completion of requirements before surgery.

Phase I: Comprehensive multidisciplinary evaluation

Phase I is coordinated by the multidisciplinary bariatric surgery program and includes a referral from the primary care provider (PCP) to the bariatric surgeon and program, confirming that applicable patient indications and program requirements are met.
The bariatric surgeon and program follow the member through the Phase I evaluation.
Required Phase I documentation
- 1. Psychosocial evaluation
  - Evaluation for substance abuse or an eating disorder.

OHCA does not provide coverage for bariatric procedures considered experimental or investigational. See Appendix A for the applicable code list and definitions.

Patients who do not meet the patient checklist criteria are not covered for bariatric surgery under OHCA guidelines.

Eligibility Thresholds and Procedure Codes

Appendix A CPT Code DescriptionCPT

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 laparoscopic procedure on stomach
43770	Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (i.e., 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 (i.e., sleeve gastrectomy)
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 17

1/2

Adult BMI eligibility without specified comorbidity

PopulationAdults ages 20 to 65

Eligibility thresholdBMI ≥ 40

Comorbidity requirementNo specified comorbidity is required for this pathway

Adult BMI eligibility with at least 1 serious comorbidity

PopulationAdults ages 20 to 65

BMI rangeBMI ≥ 35 but < 40

Comorbidity requirementAt least 1 comorbidity serious enough to warrant pharmacotherapy or treatment

Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required for Every Bariatric Procedure

Prior authorization is required for every bariatric surgery procedure, including procedures billed with unlisted procedure codes.

Submit a PA for all bariatric surgery procedures, regardless of whether the procedure code is listed or unlisted.

Documentation Required

Phase I: Comprehensive Evaluation

Phase I is a comprehensive multidisciplinary evaluation to determine whether the member is physically, mentally, and emotionally suitable for bariatric surgery and able to adhere to the required lifelong behavioral changes and strict diet.

Coordinate the evaluation through an approved multidisciplinary bariatric program.
Ensure the PCP referral, patient indications, and programmatic requirements are addressed.
Assess motivation, knowledge, readiness, and ability to follow required post-surgical lifestyle changes.

Bariatric Surgery Overview

Bariatric surgery changes the stomach and digestive system to limit food intake and nutrient absorption and produce weight loss. Procedures may include gastric bypass and other operations that alter the digestive system. OHCA coverage focuses on medically necessary bariatric care for eligible members and requires comprehensive preoperative evaluation, postoperative and behavioral-health support, nutritional services, physical activity, member motivation, and long-term follow-up to support successful outcomes.

Policy Definitions

Adjustable Laparoscopic Banding (ALB)

ProcedurePlacement of an implant around the top part of the stomach

ImplantA soft silicone ring with an expandable balloon in the center

Alternate terminologyLap Band or Realize Band

Bariatric Surgery

DefinitionGastric bypass and other weight-loss surgeries

Anatomical effectChanges are made to the digestive system

PurposeThe changes result in weight loss

Policy Summary

PayerOklahoma Health Care Authority

PolicyBariatric Surgery Coverage Criteria

Policy CodePolicy N/A

Change TypeRevision of Existing Criteria

Effective DateSeptember 7, 2023

Next Review DateAugust 2026

Key ActionObtain prior authorization for every bariatric surgery procedure, including procedures billed with unlisted procedure codes.

SourceLink

On This Page

Behavioral health services for pre-operative psychosocial evaluation and ongoing post-operative counseling as needed.

Nutritional education and counseling both before and after surgery.

Integration of the required services in an electronic medical record (EMR).

Institutional quality-assurance review of all bariatric surgery cases.

Regular clinical outcomes assessment review, such as monthly or a similar schedule.

Obstructive sleep apnea (OSA).

Obesity-hypoventilation syndrome (OHS), also known as Pickwickian syndrome.

Nonalcoholic fatty liver disease or nonalcoholic steatohepatitis.

Pseudotumor cerebri, also known as idiopathic intracranial hypertension (IIH).

Gastroesophageal reflux disease (GERD) without other risk factors, such as alcohol abuse, esophageal motility disorders, or hiatal hernia, requiring proton pump inhibitor therapy or regularly prescribed or over-the-counter medication.

Venous stasis disease.

Renal insufficiency or renal failure.

Complex ventral abdominal wall hernias.

End-organ disease requiring transplant, including end-stage renal disease (ESRD), end-stage liver disease (ESLD), or heart failure requiring a left ventricular assist device (LVAD).

Evaluation for psychiatric illness that would prevent participation in a pre-surgical weight-loss and evaluation program or successful adjustment to post-surgical lifestyle changes.

If applicable, documentation that psychiatric illness has been successfully treated and stabilized for at least 6 months.

If applicable, documentation that the member has been rehabilitated and is free from drug and alcohol use for at least 1 year.

Documented plan for long-term psychosocial follow-up.

The member may be referred to OHCA Behavioral Health Services at (405) 522-7597 for assistance finding a provider; these psychosocial evaluation services are covered by OHCA.

2. Medical evaluation by a health care professional with dedicated expertise in bariatric surgery patients, including assessment of operative morbidity and mortality risks by a physician experienced in bariatric medicine who is contracted with OHCA, cardiac risk stratification, and obstructive sleep apnea screening.

3. Surgical evaluation by an OHCA-contracted surgeon credentialed to perform bariatric surgery and participating in a comprehensive program.

4. Pre-surgery nutrition and lifestyle modification

Member participates under the supervision of an OHCA-contracted medical provider.
Nutritional counseling includes a comprehensive consultation and at least 2 follow-ups. Services may be provided by a registered dietitian (RD) and are covered by OHCA for adults.
Member participates in a supervised exercise program and maintains an exercise diary.

5. Member has successfully stopped smoking for at least 6 months; laboratory documentation may be required.

6. The program strongly considers weight loss during the 2 weeks before surgery, as appropriate based on BMI, comorbidities, and clinical situation.

Phase I documentation is submitted for prior authorization before surgery.

Phase II: Bariatric surgery prior authorization

Phase II occurs after successful completion of Phase I with an approved bariatric program and before surgical intervention.
The purpose of Phase II and the PA is to ensure that the member and program have met all OHCA Phase I requirements.
The bariatric surgeon, in conjunction with the multidisciplinary program, supplies medical records obtained during the evaluation and any other documentation showing that the member and program meet all requirements.
For Provider Portal PAR submission, use any bariatric procedure code. Current CPT codes consistent with the operation are listed in Appendix A, and the bariatric surgeon may amend the procedure code before surgery.

Adult BMI eligibility with at least 2 serious comorbidities

PopulationAdults ages 20 to 65

BMI rangeBMI ≥ 30 but < 35

Comorbidity requirementAt least 2 comorbidities serious enough to warrant pharmacotherapy or treatment

Adult dysmetabolic syndrome or difficult-to-control diabetes

BMI thresholdBMI ≥ 30

Qualifying metabolic conditionDysmetabolic Syndrome

Alternative qualifying conditionDifficult-to-control diabetes

Adolescent BMI eligibility

PopulationAdolescents ages 15 to 19

Moderate-to-severe obesity pathwayBMI ≥ 35 kg/m2 and ≤ 40 kg/m2, or ≥ 120% of the 95th percentile and < 140% of the 95th percentile

Severe obesity pathwayBMI > 40 kg/m2 or ≥ 140% of the 95th percentile

Smoking cessation

Required cessation periodMinimum 6 months

RequirementThe member should have successfully stopped smoking before surgery

DocumentationLaboratory documentation may be required

GERD complication treatment failure

ConditionGastroesophageal reflux disease (GERD)

Treatment responseUnresponsive to acid suppression treatment

Minimum treatment duration≥ 8 weeks

Repeat surgery inadequate weight loss

TimingTwo years following the primary bariatric surgery procedure

Weight-loss thresholdHas not lost more than 50% of excess body weight

Additional requirementsCompliance with prescribed nutrition and exercise programs and meeting the initial bariatric procedure criteria

Documentation Required

Phase I Evaluation Records

Maintain and submit complete Phase I evaluation records for the bariatric surgery PA. Documentation must support the member’s readiness, medical suitability, operative risk, and ability to participate in required lifestyle changes.

Psychosocial evaluation, including substance-use or eating-disorder assessment, psychiatric evaluation, stabilization or rehabilitation documentation when applicable, and a long-term psychosocial follow-up plan.
Medical evaluation by an OHCA-contracted professional experienced in bariatric medicine, including operative morbidity and mortality assessment, cardiac risk stratification, and obstructive sleep apnea screening.
Surgical evaluation by an OHCA-contracted, bariatric-credentialed surgeon participating in a comprehensive program.

Prior Authorization

Phase II: Surgical Prior Authorization

After successful completion of Phase I with an approved bariatric program, submit the Phase II surgical PA request before the surgical intervention.

Phase II confirms that the member and program have met all OHCA Phase I requirements.
The bariatric surgeon and multidisciplinary program must submit the evaluation-phase medical records and any additional documentation supporting the surgical request.

Billing Rule

Provider Portal PAR Procedure Code

For the Provider Portal PAR submission, use any bariatric procedure code. The bariatric surgeon may amend the procedure code before surgery to reflect the operation to be performed.

Use a bariatric procedure code for the initial PAR submission.
Amend the code before surgery when needed.

Documentation Required

Provider and Facility Credentials

To be eligible for reimbursement, bariatric surgery providers and facilities must meet OHCA accreditation, contracting, credentialing, and quality requirements on an ongoing basis.

Maintain ACS MBSAQIP Comprehensive Bariatric Surgery Center certification, or participate in a qualifying multidisciplinary quality-assurance and clinical-outcomes pathway to accreditation.
Ensure the surgeon has qualifying bariatric fellowship, ASMBS fellowship, or MBSAQIP-verified credentials.
Ensure the facility and providers are contracted with OHCA and maintain a demonstrated quality-assurance record.
Provide OHCA proof of required certifications annually.

Documentation Required

Bariatric Program Requirements

Bariatric programs must maintain sustainable infrastructure for pre-operative, post-operative, and long-term follow-up care and provide the required multidisciplinary services.

Maintain long-term programmatic commitment and continuity of care for Oklahoma bariatric patients.
Provide bariatric and minimally invasive surgical expertise, comprehensive medical care, behavioral health services, and pre- and post-operative nutritional counseling.
Integrate required services in the electronic medical record and conduct institutional quality-assurance and regular clinical-outcomes reviews.

Denial Risk

Patient Checklist Must Be Met

The bariatric program must verify that the member meets the OHCA patient checklist before requesting authorization. Members who do not meet these criteria are not covered for bariatric surgery under the guideline.

Age must be 15 through 65 years.
Adults ages 20–65 must meet an applicable BMI threshold and comorbidity pathway, including BMI ≥40; BMI 35–<40 with at least one serious qualifying comorbidity; BMI 30–<35 with at least two; or BMI ≥30 with dysmetabolic syndrome or difficult-to-control diabetes.
Adolescents ages 15–19 must meet the applicable BMI or percentage-of-95th-percentile threshold.
Document qualifying obesity-related comorbidities when required, such as diabetes, hypertension, CAD, obstructive sleep apnea, obesity-hypoventilation syndrome, and other listed conditions.
The member must not be pregnant or planning pregnancy within the next two years and must be an appropriate surgical candidate.

Documentation Required

Phase II Submission

Submit Phase I records and all additional documentation needed to establish that the member and bariatric program satisfy OHCA requirements for the requested surgery.

Include the psychosocial, medical, surgical, nutrition, exercise, and smoking-cessation documentation obtained during Phase I.
Document completion of Phase I with the approved bariatric program before submitting the Phase II request.
Submit the request before surgical intervention.

Documentation Required

Nutrition and Exercise Participation

Document participation in the required nutrition and lifestyle-modification program before surgery under the supervision of an OHCA-contracted medical provider.

Provide nutritional counseling with a minimum of two follow-ups after a comprehensive consultation; adult services may be provided by a registered dietitian and are covered by OHCA.
Document participation in a supervised exercise program with a member-maintained exercise diary.
Consider weight loss during the two weeks before surgery when clinically appropriate based on BMI, comorbidities, and the clinical situation.

Documentation Required

Smoking Cessation

Document successful smoking cessation before surgery. Laboratory documentation may be required.

The member should have stopped smoking for at least six months.
Retain laboratory evidence of cessation when required.

Denial Risk

Experimental or Investigational Procedures

OHCA does not cover bariatric procedures considered experimental or investigational.

Do not submit experimental or investigational bariatric procedures as covered services under OHCA guidelines.
Review Appendix A for procedure-code definitions and applicable code information.

Denial Risk

Provider or Program Requirements Not Met

Reimbursement may be denied when provider, facility, or program requirements are not met, including accreditation, contracting, credentialing, quality-assurance, or long-term-care obligations.

Maintain required accreditation or an approved pathway to accreditation.
Keep the surgeon, facility, and program contracted and appropriately credentialed with OHCA.
Maintain required multidisciplinary services, continuity of care, electronic-record integration, and quality/outcomes review.
Provide required certification proof to OHCA annually.

Denial Risk

Incomplete Two-Phase Authorization

Authorization and payment are at risk when the required two-phase process is incomplete or the submitted documentation does not establish compliance with Phase I and Phase II requirements.

Do not submit Phase II until the member has successfully completed Phase I with an approved bariatric program.
Include complete psychosocial, medical, surgical, nutrition, exercise, smoking-cessation, and other supporting records.
Submit the Phase II PA before surgery and include documentation that both the member and program meet OHCA requirements.

Denial Risk

Noncompliance May Withdraw Payment Authorization

OHCA may withdraw authorization of payment for bariatric surgery at any time if the member, provider, or bariatric program is not in compliance with any guideline requirement.

Monitor ongoing compliance by the member, provider, facility, and program.
Correct noncompliance promptly to avoid withdrawal of authorization or payment.

Body Mass Index (BMI)

MeasureA measure of body fat based on height and weight

Weight unitWeight in kilograms

CalculationWeight in kilograms divided by the square of height in meters

Diabetes Mellitus

Diabetes definitionHbA1C level of 6.5% or taking a Type 2 Diabetes Mellitus medication prescription for more than one year

Moderately or poorly controlledA1C ≥ 6.8%

Well-controlledA1C ≤ 6.8%

Dysmetabolic Syndrome

Required glucose conditionType 2 diabetes mellitus or impaired glucose tolerance

Additional requirementTwo of the listed qualifying criteria must also be present

Qualifying criteriaHypertension, dyslipidemia, obesity or abdominal obesity, or microalbuminuria

Gastric Sleeve

Alternate nameVertical Sleeve Gastrectomy

ProcedureA bariatric weight-loss surgery

Anatomical changeRemoves 75% to 80% of the stomach, leaving a thin vertical sleeve or tube

Obesity

Obesity thresholdBMI ≥ 30

Class IBMI 30-34.9

Class II and IIIClass II: BMI 35-39.9; Class III or clinically severe obesity: BMI ≥ 40

Roux-en-Y Gastric Bypass (RYGB)

Procedure typeA type of weight-loss surgery

Stomach alterationCreates a small pouch from the stomach

Intestinal connectionConnects the newly created pouch directly to the small intestine

Gastroesophageal Reflux Disease (GERD)

ConditionA chronic, relapsing condition

SymptomsHeartburn, regurgitation, and possibly dysphagia

ImpactAssociated with morbidity and an adverse impact on quality of life

Hypertension

Systolic criterionSystolic blood pressure of 140 mmHg or greater

Diastolic criterionDiastolic blood pressure of 90 mmHg or greater

Treatment criterionRequires hypertensive medication

Laparoscopic or Laparoscopy

TechniqueA surgical diagnostic procedure

PurposeUsed to examine organs inside the abdomen

IncisionsA minimally invasive procedure requiring only small incisions

Obstructive Sleep Apnea (OSA)

ConditionAn increase in respiratory effort

CauseBreathing against relative or absolute airway obstruction

Airflow effectDecreased or absent airflow

Degenerative Disc Disease

Alternate nameDiscopathy

Anatomical siteVertebral discs

Clinical effectMay cause acute or chronic low back pain through loss of intervertebral disc structure or integrity

Degenerative Joint Disease

Alternate nameOsteoarthritis

Disease typeA noninfectious progressive disorder

EffectGradual deterioration of cartilage covering the weight-bearing joints

Degenerative Spinal Disease (DSD)

Alternate nameSpondylosis deformans

Spinal structuresMay affect the entire disco-vertebral unit or functional spinal unit

Pathologic processIntervertebral disc degeneration leads to bony spurs or bridges around the disc and nearby spinal joints

Venous Stasis Syndrome

Vascular conditionVenous insufficiency or venous incompetence

Symptoms and findingsDependent leg pain and swelling, skin pigmentation, eczematous dermatitis, and lipodermatosclerosis

Additional mechanismsVenous valvular incompetence or venous outflow obstruction