Modifiedpartners_health_managementPolicy NC.CP.MP.37

Bariatric Surgery — Coverage Criteria and Coding Updates

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Defines medical necessity, preoperative requirements, repeat/conversion surgery rules, investigational and not-medically-necessary bariatric procedures for members of plans affiliated with Centene/Partners Health Management.

Policy Summary

Payerpartners_health_management

PolicyBariatric Surgery — Coverage Criteria and Coding Updates

Policy CodePolicy NC.CP.MP.37

Change TypeMaterial revisions to criteria, coding, and preoperative requirements

Effective DateN/A

Last ReviewApr 1, 2026

Next Review DateApr 1, 2026

Key ActionObtain prior authorization with documentation showing age, BMI, comorbidities, and required preoperative evaluations completed within six months.

SourceLink

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Modifiedpartners_health_managementPolicy NC.CP.MP.37

Bariatric Surgery — Coverage Criteria and Coding Updates

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Policy Summary

Payerpartners_health_management

PolicyBariatric Surgery — Coverage Criteria and Coding Updates

Policy CodePolicy NC.CP.MP.37

Change TypeMaterial revisions to criteria, coding, and preoperative requirements

Effective DateN/A

Last ReviewApr 1, 2026

Next Review DateApr 1, 2026

Key ActionObtain prior authorization with documentation showing age, BMI, comorbidities, and required preoperative evaluations completed within six months.

SourceLink

POLICY UPDATE CHANGES

Updated BMI thresholds and expanded ethnicity-specific BMI criteria; moved Type 2 diabetes mellitus within criteria and added several comorbidities and clarifications to indications and exclusions.

Added list of procedures/devices considered investigational or inadequately supported by current literature (e.g., one-anastomosis gastric bypass; endoscopic sleeve gastroplasty; vagus nerve blocking; various gastric balloons).

Updated CPT code lists: added and removed multiple CPT codes from the 'not medically necessary' table and 'do not support medical necessity' lists.

Clarified requirements and evaluations (e.g., H. pylori testing methods; pulmonary PSG guidance; glycemic evaluation includes A1c and fasting glucose).

Removed high risk for type 2 DM from a listed criterion and changed 'poorly controlled hypertension' language to 'hypertension' in a criterion.

Added single-anastomosis duodenoileal bypass (SADI)/SADI-S as a described procedure and added CPT code 43999 for SADI-S.

SpecifiedBMI criteria

13+Investigational procedures

multipleCPT codes NMN

AspireAssistDevices discussed

annualReview cycle

Coverage Criteria and Indications

Initial bariatric surgery (medical necessity)

Covered when ALL of the following are met:

Overall: Patient meets both A and B requirements

Sections A and B must be satisfied

A. Medical history

Adult age/BMI branch
- (i): BMI ≥ 32.5 kg/m2 for South Asian, Southeast Asian, and East Asian OR ≥ 35 kg/m2 for all other ethnicities when LAGB, LSG, RYGB, SADI-S, or BPD-DS/BPD-GRDS is requested
  Supports listed procedure types
- (ii): BMI ≥ 27.5 and < 32.5 kg/m2 for South Asian, Southeast Asian, and East Asian adults OR ≥ 30 and < 35 kg/m2 for all other ethnicities, AND at least one of: (a) type 2 diabetes mellitus OR (b) at least one obesity-related comorbidity that has not improved despite nonsurgical weight loss methods (examples include hypertension; dyslipidemia; obstructive sleep apnea; obesity-hypoventilation syndrome; nonalcoholic fatty liver disease/NASH; pseudotumor cerebri; coronary artery disease; gastroesophageal reflux disease; asthma; venous stasis disease; bone and joint diseases; disqualification from other specialty surgeries due to obesity; chronic kidney disease; infertility; polycystic ovarian syndrome; limitation of motion in weight-bearing joint or lumbosacral spine; cardiomyopathy and heart failure; pulmonary hypertension; carotid artery disease; aortic disease; atrial fibrillation; heart failure)
  Comorbidities enumerated in policy
Adolescent branch: Age <18: LSG or laparoscopic RYGB requested AND BMI ≥ 35 kg/m2 or ≥120% of the 95th percentile (whichever is lower)
Additional pediatric considerations referenced elsewhere

B. Preoperative evaluation: Within six months: (1) medical evaluation from a physician other than the surgeon, preferably the member's PCP, including recommendation and medical clearance for the requested procedure; (2) nutritional evaluation by a qualified provider; and (3) age-appropriate psychiatry/psychology consultation stating the member is a suitable candidate and mental health disorders are adequately managed.6 months

All three required

Repeat, revision, or conversion bariatric surgery

Covered when ANY of the following indications are met and additional criteria are satisfied:

Indications: A. To correct complications from a previous bariatric surgery (e.g., obstruction, strictures) including conversion to LSG, RYGB, or BPD-DS (adults/adolescents as appropriate); B. Conversion from LAGB to LSG, RYGB, SADI-S, or BPD-DS; C. Conversion of SG to RYGB for treatment of GERD after failed anti-reflux medical therapy; D. Conversion of SG to RYGB or BPD-DS as a bridging procedure for BMI ≥ 50 kg/m2

For revision due to failed primary procedure, additional criteria below apply

Revision for failed primary procedure: All of the following must be met: (1) all criteria listed for the initial bariatric procedure are met again; (2) weight loss from the initial procedure was less than 50% of the member's excess body weight at the time of the initial procedure; (3) if conversion is requested due to removal of an eroded LAGB, at least two months have passed since band removal; (4) documented compliance with previously prescribed postoperative nutrition and exercise program; (5) supporting documentation from the provider including clinical explanation of why the procedure failed

Applies to conversions/revisions

Investigational procedures (insufficient evidence)

Procedures considered investigational (evidence inadequate to determine safety/efficacy):

Investigational list: Distal (very long limb) gastric bypass; mini-gastric/one-anastomosis gastric bypass; laparoscopic re-sleeve gastrectomy; Fobi pouch; laparoscopic greater curvature plication (gastric imbrication); stomach aspiration therapy (e.g., AspireAssist); endoscopic suture revisions post bariatric surgery; gastric plication/endoluminal vertical gastroplasty; endoscopic gastrointestinal bypass devices (EGIBD); endoscopic sleeve gastroplasty; transoral endoscopic surgery; vagus nerve blocking (e.g., Maestro); gastric balloon devices (e.g., ReShape Duo, Orbera, Obalon)

Listed as investigational pending adequate long-term data

Not medically necessary procedures

The following are considered not medically necessary due to potential complications and lack of positive outcomes:

Not medically necessary list: Biliopancreatic diversion (Scopinaro), jejunoileal bypass (jejuno-colic bypass), vertical banded gastroplasty (VBG), gastric pacing/gastric electrical stimulation, gastric wrapping

These procedures are explicitly not medically necessary

Not Medically Necessary Procedures — group

Procedures explicitly identified as Not Medically Necessary

Not Medically Necessary Procedures: Includes: Biliopancreatic Diversion (Scopinaro BPD) and BPD/DS description; Jejunoileal Bypass (JIB) abandoned due to high complication rates and no longer recommended; Vertical Banded Gastroplasty (VBG) fallen out of favor and associated with staple failure/mesh risks; gastric balloon devices previously removed from market for migration/obstruction risks; gastric pacing abandoned due to lack of long-term effect; gastric wrapping is new with insufficient peer-reviewed evidence.

Each listed procedure or technique is described in the policy as not medically necessary or no longer recommended.

Initial eligibility and procedure indications

Coverage is medically necessary when the policy sections A and B criteria are met (sections referenced I.A and I.B).

Adult and procedural indications: Includes updated procedure list with SADI/SADI-S added and BMI-based indications; special BMI ranges for specified Asian populations apply; comorbidity list updated to add chronic kidney disease, infertility, polycystic ovarian syndrome, atrial fibrillation, heart failure and other conditions; consolidated preoperative requirements I.B.1–I.B.3 apply.see BMI thresholds and comorbidity list

See Sections I.A and I.B for exact nested criteria (ethnicity-specific BMI thresholds and enumerated comorbidities)

Revisional surgery criteria

Revisional and conversion procedures

Revisional procedures: SADI-S is listed as medically necessary when performed as conversion/revisional surgery (for example following LAGB); SADI/SADI-S has been removed from the investigational list and CPT 43999 is referenced for SADI-S coding.N/A

Follow the revision/conversion criteria and documentation requirements in Section II for revisional specifics.

The policy explicitly identifies several older bariatric procedures as not medically necessary because of high complication rates and lack of durable benefit. Examples named in the policy include biliopancreatic diversion (Scopinaro), jejunoileal bypass, vertical banded gastroplasty (VBG), gastric pacing/gastric electrical stimulation, and gastric wrapping. These procedures are excluded from coverage due to documented risks and limited contemporary use.

The document states that jejunoileal bypass (JIB) and vertical banded gastroplasty (VBG) are effectively abandoned as recommended bariatric surgical procedures. JIB is no longer performed because of historical high complication and revision rates, and professional guidance (ASMBS) no longer recommends its use. VBG has fallen out of favor compared with adjustable gastric banding and is described as essentially no longer performed by CMS, supporting its exclusion from coverage.

The policy's "not medically necessary" table was revised to remove deleted CPT codes 0312T–0317T and to add CPT codes 43290, 43291, and 43632 into the not medically necessary listing. This coding update reflects the policy's reassessment of specific endoscopic and surgical procedure codes and aligns the code table with the current coverage stance.

When state Medicaid program rules conflict with this clinical policy, the state Medicaid coverage provisions take precedence for Medicaid members. For Medicare members, the policy instructs reviewers to consult applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Coverage Articles to ensure consistency before applying this policy's criteria.

The policy specifically lists procedures considered not medically necessary, including biliopancreatic diversion (Scopinaro), jejunoileal bypass (jejuno-colic bypass), vertical banded gastroplasty, gastric pacing/gastric electrical stimulation, and gastric wrapping. Each is discussed in the policy text as having unacceptable complication profiles or insufficient evidence to support routine coverage.

The policy groups several procedures as not medically necessary, naming BPD and BPD/DS (Scopinaro), jejunoileal bypass (JIB), vertical banded gastroplasty (VBG), and various gastric balloon devices or other endoscopic/novel techniques that have been removed from the market or lack long-term outcome data. The text explains historical reasons (e.g., malabsorption complications, device migration, stenosis) for excluding these options.

Procedures formerly associated with deleted CPT codes 0312T–0317T are no longer enumerated in the policy. In their place, specific procedures tied to CPT codes 43290, 43291, and 43632 have been placed into the not medically necessary table, consistent with the document's coding revisions.

Coding and Billing

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.

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	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.
64595	Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver.

Additional neurostimulator CPT codes referencedCPT

64590

Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling.

HCPCS codes that support medical necessityHCPCSCovered

S2083

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

Policy coding updates (added/removed)CPT

0312T	deleted CPT code (previously listed)
0313T	deleted CPT code (previously listed)
0314T	deleted CPT code (previously listed)
0315T	deleted CPT code (previously listed)
0316T	deleted CPT code (previously listed)
0317T	deleted CPT code (previously listed)
43290	Added to not medically necessary table
43291	Added to not medically necessary table
43632	Added to not medically necessary table
43999	CPT code added for SADI-S procedure

inv-20: BMI — Adults

Adult BMI threshold (standard)BMI ≥ 35 kg/m2 for non-Asian adults when LAGB, LSG, RYGB, SADI-S, or BPD-DS/BPD-GRDS is requested

Adult BMI threshold (South/Southeast/East Asian)BMI ≥ 32.5 kg/m2 for South Asian, Southeast Asian, and East Asian adults when LAGB, LSG, RYGB, SADI-S, or BPD-DS/BPD-GRDS is requested

Adult BMI with comorbidity (non-Asian)BMI ≥ 30 and < 35 kg/m2 for non-Asian adults when LAGB, LSG, RYGB, SADI/SADI-S, or BPD-DS/BPD-GRDS is requested AND at least one qualifying comorbidity or type 2 diabetes mellitus

Adult BMI with comorbidity (Asian)BMI ≥ 27.5 and < 32.5 kg/m2 for South Asian, Southeast Asian, and East Asian adults when specified procedures are requested AND at least one qualifying comorbidity or type 2 diabetes mellitus

Adolescent BMI threshold

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior authorization required for initial bariatric surgery

Prior authorization is required for initial bariatric procedures. Requests must document that the patient meets the age and BMI criteria and that the required preoperative evaluations (medical evaluation from a physician other than the surgeon, nutritional evaluation, and age‑appropriate psychiatry/psychology consultation) were completed within six months of the requested surgery.

Age and BMI criteria per I.A.1 (including ethnicity‑specific BMI thresholds) must be met.
Preoperative medical, nutritional, and psychiatric/psychological evaluations must be completed within six months.

Prior Authorization

Prior authorization for listed CPT/HCPCS codes

Prior authorization is required for procedures billed under the CPT/HCPCS codes listed as supporting medical necessity; authorizations should reference the applicable CPT/HCPCS codes when submitting requests.

Include one of the CPT codes listed as 'CPT codes that support medical necessity' (e.g., 43644, 43775, 43843) or HCPCS S2083 as applicable.

Background and Evidence Summary

Severe obesity is associated with increased mortality and multiple obesity-related comorbidities, and the policy notes that surgical treatment is the only proven modality for long-term weight control in morbid obesity. Common contemporary bariatric procedures referenced in the policy include sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (LAGB), and biliopancreatic diversion with duodenal switch (BPD-DS), while also documenting that historically used procedures (e.g., JIB, VBG, gastric balloons, gastric pacing) have been abandoned or are not recommended due to safety and outcome concerns. The policy emphasizes the importance of patient selection, long-term follow-up, and procedure-specific evidence when considering surgery.

Definitions

inv-42: Restrictive procedures

DefinitionRestrictive procedures create a small stomach pouch to limit food intake, producing weight loss

Common examplesLaparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG)

Procedure selection factorsChoice of restrictive procedure should consider BMI, comorbidity profile, treatment goals, surgeon expertise, and patient preference

inv-43: Malabsorptive procedures

DefinitionMalabsorptive procedures bypass portions of the stomach and/or small intestine to reduce digestion and nutrient absorption

Common examplesDuodenal switch (part of BPD-DS) and Roux-en-Y gastric bypass (when malabsorptive mechanisms are present)

Policy Summary

Payerpartners_health_management

PolicyBariatric Surgery — Coverage Criteria and Coding Updates

Policy CodePolicy NC.CP.MP.37

Change TypeMaterial revisions to criteria, coding, and preoperative requirements

Effective DateN/A

Last ReviewApr 1, 2026

Next Review DateApr 1, 2026

Key ActionObtain prior authorization with documentation showing age, BMI, comorbidities, and required preoperative evaluations completed within six months.

SourceLink

On This Page

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

inv-21: BMI thresholds (ethnicity-specific)

Revised adult ethnicity-specific BMI policyPolicy updated to specify BMI thresholds of ≥35 kg/m2 for most adults and ≥32.5 kg/m2 for South/Southeast/East Asian adults for primary procedures; additional ethnicity-specific ranges retained for comorbidity pathways

Moved and clarified comorbidity placementType 2 diabetes mellitus relocated within criteria as an absolute comorbidity for lower-BMI pathways; several obesity-related comorbidities were added or clarified

Documentation of revisionsRevision history entries document the BMI threshold changes and related policy text updates across sections I.A.1.a.i and I.A.1.a.ii

inv-22: BMI thresholds (selected references)

Selected referenced BMI adjustment (low-BMI adult pathway)For age ≥18, some Asian adults: BMI ≥27.5 and <32.5 kg/m2 qualifies for certain procedures when type 2 diabetes or an obesity-related comorbidity is present

Standard low-BMI adult pathway (non-Asian)BMI ≥30 and <35 kg/m2 for non-Asian adults with type 2 diabetes or listed comorbidity to qualify for specified procedures

Context for adolescent criteriaAdolescent BMI criteria reference age <18 with BMI ≥35 kg/m2 or ≥120% of 95th percentile for LSG or RYGB

inv-23: GFR threshold (pediatric)

Pediatric GFR threshold (updated)GFR < 60 mL/min/1.73 m2 (revised from prior threshold of <30 mL/min/1.73 m2)

Where appliedGFR threshold referenced in preoperative medical evaluation subcriteria for pediatric patients

Revision noteChange documented in revision history clarifying pediatric renal function requirement

Claims for codes in the 'do not support medical necessity' table may not be approved.

Prior Authorization

Procedure‑specific prior authorization (SADI/SADI‑S)

Procedure‑specific prior authorization applies; SADI/SADI‑S is specifically included in the policy and CPT code 43999 is referenced for SADI‑S—prior authorization requests for SADI/SADI‑S should include that procedure/crosswalk information.

SADI/SADI‑S was added to the criteria and CPT code 43999 was added for SADI‑S.
Submit prior authorization citing the SADI/SADI‑S inclusion and appropriate code.

Prior Authorization

Prior authorization guidance and plan-level requirements

The clinical policy is guidance to assist in coverage decisions; prior authorization may be required per the Health Plan's administrative policies and the policy does not guarantee payment.

Follow the Health Plan's administrative prior authorization procedures and timelines.
Authorization decisions remain subject to plan terms, exclusions, and state/federal requirements.

Step Therapy

Document conservative treatment attempts before surgery

Conservative (nonsurgical) weight‑loss attempts and a multidisciplinary approach should be attempted and documented prior to surgery for many patients, particularly those with lower BMI indications.

Document prior diet, exercise, and behavioral interventions and outcomes.
For class I obesity and certain comorbidities, demonstrate failure of reasonable nonsurgical methods per guideline expectations.

Step Therapy

Adjunctive lifestyle counseling required for AspireAssist

For AspireAssist, the device is intended to be used in conjunction with diet and exercise and clinical trials required adjunctive lifestyle counseling; prior authorization requests should document concurrent lifestyle counseling.

Document that the member will receive lifestyle counseling alongside device use.
Include trial‑based support showing AspireAssist was used with counseling when applicable.

Step Therapy

Follow revisional procedure sequencing and criteria

When requesting revisional procedures or conversions, follow the policy's sequencing and revision criteria—SADI‑S may be medically necessary as a conversion following LAGB; include documentation that revision/conversion criteria are satisfied.

If conversion follows an eroded LAGB, document at least two months between band removal and the subsequent procedure.
Ensure prior procedure criteria, weight‑loss failure (<50% excess body weight loss), and documented compliance are included.

Documentation Required

Submit required preoperative medical, nutritional, and psychiatric documentation

Required preoperative documentation must be submitted with authorization requests: medical evaluation from a physician other than the surgeon (including recommendation and medical clearance), a nutritional evaluation by a qualified provider, and an age‑appropriate psychiatry/psychology consultation stating suitability and mental health stability—all completed within six months of surgery.

Medical evaluation should recommend and clear the patient for surgery and is required within six months.
Nutritional and psychiatric/psychological assessments must state candidate suitability and plan for postoperative management.

Documentation Required

Documentation required for repeat/revision/conversion requests

For repeat, revision, or conversion surgery requests include documentation of prior procedure failure (clinical explanation), objective weight‑loss data demonstrating less than 50% excess body weight loss since the initial procedure, documentation of compliance with postoperative nutrition and exercise, and timing if the revision follows band erosion/removal.

Show weight loss from the initial procedure was <50% of excess body weight at time of initial procedure.
If revision follows eroded LAGB removal, document at least a two‑month interval since removal.

Documentation Required

Include required preoperative testing and results

Preoperative testing and documentation expectations must be met and included with requests—H. pylori screening should be performed by urea breath test or stool antigen test; glycemic evaluation should include A1c and fasting glucose; pulmonary evaluation with polysomnography (PSG) only if OSA screening is positive; and examples of nutritional tests should be provided as indicated.

H. pylori: urea breath test or stool antigen test per policy.
Glycemic evaluation: include A1c and fasting blood glucose.
Pulmonary PSG only if screening for OSA is positive.

Documentation Required

Non‑surgeon preoperative medical evaluation required when indicated

A preoperative medical evaluation from a physician other than the surgeon is required for preoperative clearance when indicated by cardiac or pulmonary comorbidities; the policy consolidated preoperative requirements to require this non‑surgeon medical evaluation.

Obtain evaluation/clearance from PCP or appropriate specialist (cardiologist/pulmonologist) as indicated.
Document the evaluator's recommendation and clearance in the authorization record.

Note

Follow plan coverage terms, exclusions, and administrative policies

Providers must follow the member's coverage documents and applicable state/federal requirements when submitting claims and documentation; failure to comply with plan terms, exclusions, or administrative policies can affect authorization and payment.

Verify plan‑specific terms, exclusions, limits, and state Medicaid or Medicare NCD/LCD requirements prior to submission.
Adhere to Health Plan administrative prior authorization procedures.

Denial Risk

Denial risk if BMI, age, or preoperative criteria are missing

Requests that do not meet the policy's specified BMI and age criteria or that lack the required preoperative evaluations and clearances may be denied for failing to meet medical necessity criteria.

Ensure documentation demonstrates compliance with I.A (age/BMI/comorbidity) and I.B (preoperative evaluations) before submission.
Incomplete or out‑of‑date evaluations (older than six months) increase denial risk.

Denial Risk

Denial risk for listed not‑medically‑necessary CPT codes

Claims for procedures and CPT codes listed in the 'do not support medical necessity' / not medically necessary tables (examples include CPT 43290, 43291, 43632, 43647, 43648, 43842, 43847, 43881, 43882, 64595) may be denied as not supporting medical necessity.

Verify that the CPT code submitted is in the 'support medical necessity' list; if not, expect potential denial.
If using an unlisted or revised code, include detailed operative notes and clinical justification.

Billing Rule

Avoid deleted or outdated CPT codes on submissions

Do not submit requests using deleted CPT codes (0312T–0317T); referencing deleted codes or failing to use updated coding may create administrative issues or denials—policy updates removed those deleted codes and added several codes to the not medically necessary table.

Remove any references to deleted CPT codes 0312T–0317T in requests.
Confirm current CPT crosswalks (e.g., 43999 added for SADI‑S) and use current codes.

Note

Coverage and document compliance affects authorization and payment

Follow the coverage documents and Health Plan administrative policies; coverage decisions and administration of benefits are subject to all plan terms, exclusions, and limitations and applicable legal/regulatory requirements.

Coverage guidance in this policy does not guarantee payment—confirm member benefits and plan limitations.
Comply with state/federal requirements and Health Plan‑level procedures.

Complex variantsProcedures combining restrictive and malabsorptive mechanisms include BPD-DS, BPD-GRDS, and some forms of RYGB or SADI-S

inv-44: AspireAssist System

Device descriptionAspireAssist System is an FDA-approved weight-loss device consisting of an endoscopically placed percutaneous gastrostomy tube plus an external device to drain about 30% of each meal

Intended useDesigned to be used in conjunction with diet and exercise and adjunctive lifestyle counseling per clinical studies

Evidence summaryOne-year RCT (n=207) showed greater weight loss with AspireAssist plus counseling versus counseling alone; limited longer-term comparative data exist

inv-45: Endoluminal vertical gastroplasty/gastric plication

Technique descriptionEndoluminal vertical gastroplasty (gastric plication) uses endoscopic suction to approximate anterior and posterior stomach walls and secures them to create a tubular stomach similar to sleeve gastrectomy

PurposeAttempted to provide an endoscopic restrictive procedure analogous to surgical sleeve gastrectomy

Evidence limitationLong-term outcomes and durability remain limited in the literature

inv-46: Endoscopic gastrointestinal bypass devices (EGIBD / endobarriers)

Device classEndoscopic gastrointestinal bypass devices (EGIBD / endobarriers) are barrier devices placed to prevent absorption in the proximal small intestine (example: EndoBarrier)

Intended effectReduce nutrient absorption by excluding the proximal small bowel lumen from contact with food

Evidence limitationLong-term data and outcomes after device removal are lacking

inv-47: SADI / SADI-S

Procedure nameSingle-anastomosis duodenoileal bypass (SADI) / SADI-S (with sleeve gastrectomy) is now included in the policy as a described procedure

MechanismCombines restrictive (sleeve) and malabsorptive components with a single intestinal anastomosis

Coding notePolicy revision added CPT crosswalk—CPT code 43999 is referenced for SADI-S in coding updates

inv-48: Health Plan

Health Plan definitionHealth Plan: a health plan that has adopted this clinical policy and is operated or administered, in whole or in part, by Centene Management Company, LLC, or affiliates

Policy purposeThis clinical policy provides guidance to assist in making coverage decisions and administering benefits; it is not a contract or guarantee of payment

ApplicabilityCoverage decisions remain subject to the terms, conditions, exclusions and limitations of the member's coverage documents and applicable state/federal requirements