Premera Bluecross Bariatric Surgery Coverage Update

Coverage Criteria — Bariatric & Metabolic Surgery

Initial selection criteria for adults with Class II or III obesity

Bariatric surgery may be considered medically necessary when ALL of the following are met for adults with Class II or III obesity:

Adult Class II/III selection: 1) BMI criteria: Class III (BMI >= 40 kg/m2 — or >=37.5 kg/m2 for some Asian individuals) OR Class II (BMI 35.0–39.9 kg/m2 — or 32.5–37.4 kg/m2 for some Asian individuals) with at least ONE clinically significant obesity-related comorbid condition (examples: established coronary heart disease, other atherosclerotic disease, uncontrolled/resistant hypertension despite >=2 medications, peripheral arterial disease, symptomatic carotid disease, Type 2 diabetes with inadequate glycemic control [HbA1c >=7%]).see BMI thresholds

Comorbid conditions listed are examples drawn from policy; documentation of clinical significance required.

Conservative management and supervised program: 2) Documented failure of conservative weight-loss measures and participation in a physician-administered weight reduction program lasting at least 3 continuous months within the 12-month period before surgery (documentation may include physician-supervised programs or structured commercial programs under physician supervision).3 months

Provider must review and document prior nonsurgical attempts; surgeon summary letter alone is insufficient.

Behavioral and mental health clearance: 3) Mental health evaluation and clearance by a licensed mental health provider to rule out contraindicating mental health disorders, inability to provide informed consent, or inability to comply with pre- and postoperative requirements.N/A

A surgeon's summary letter alone is not adequate documentation.

Surgical setting and provider qualifications: 4) Procedure to be performed by a surgeon with specialized bariatric training and experience at a facility with appropriate multidisciplinary capabilities for preoperative and postoperative bariatric care.N/A

Facility should have staff experienced in managing bariatric patients, including comorbidity and psychosocial support.

Selection criteria for adults with Type 2 diabetes and class obesity

Adults with Type 2 diabetes and Class obesity (BMI 30–34.9 kg/m2) may be considered when ALL of the following are met:

T2 diabetes selection: 1) BMI 30.0–34.9 kg/m2 (or the adjusted lower BMI threshold for certain Asian populations) AND documented Type 2 diabetes with inadequate glycemic control (HbA1c >=7%) despite lifestyle modification and use of antidiabetic medications.HbA1c >=7%

Asian population BMI adjustments are noted in policy; a surgeon summary letter alone is insufficient documentation.

Participation in supervised program: 2) Participation in a physician-administered weight reduction program lasting at least three continuous months within the 12‑month period before surgery, or documentation of participation in a structured weight reduction program under physician supervision.3 months

Records should include program type and duration; surgeon summary letter alone is insufficient.

Mental health clearance and documentation:

Adolescent selection criteria

Adolescents (<18 years) selection criteria:

Adolescent criteria: 1) Health plan allows bariatric surgery for individuals younger than 18 years (refer to member contract for benefit determination). 2) Meets the same individual selection criteria as adults with Class II or III obesity (see adult criteria). 3) The treating facility has experienced staff to support adolescents, including psychosocial, informed consent, and multidisciplinary care appropriate for pediatric patients.age <18

Devices used for adjustable gastric banding are not FDA‑approved for individuals <18 years; procedure selection should consider device labeling and pediatric guidance.

Revision, conversion, and reoperation criteria

Revision, conversion, and reoperation criteria:

Revision for complications: Revision bariatric surgery (replacement, removal, or surgical repair) is medically necessary to address perioperative or late complications from the primary bariatric procedure, including but not limited to band erosion, slippage, leakage, herniation, intractable nausea/vomiting not correctable with adjustment, component malfunction, non‑absorption with hypoglycemia or malnutrition, obstruction, staple‑line failure (e.g., gastrogastric fistula), and strictures.N/A

Revision may be performed as a separate procedure or combined with conversion to another covered bariatric procedure.

Conversion for GERD after sleeve: Conversion of sleeve gastrectomy to Roux‑en‑Y gastric bypass for symptomatic gastroesophageal reflux disease (GERD) is medically necessary when reflux is documented by abnormal 24‑hour pH monitoring or endoscopic esophagitis after sleeve gastrectomy and symptoms persist despite optimal medical therapy (e.g., 8 weeks of daily PPI therapy).8 weeks PPI

Documentation of objective testing (pH monitoring or endoscopy) and failure of medical therapy required.

Not medically necessary and investigational procedures

Procedures considered not medically necessary or investigational:

Not medically necessary: Routine liver biopsy during obesity surgery in the absence of preoperative signs or symptoms of liver disease, and repair of hiatal hernia at the time of bariatric surgery in the absence of a preoperative diagnosis with clinical indications, are considered not medically necessary. Bariatric surgery is considered not medically necessary for adults with BMI <35 kg/m2 who do not have Type 2 diabetes.N/A

Documented preoperative indications are required for hiatal hernia repair; routine liver biopsy without clinical indication is not supported.

Investigational procedures: The following procedures are considered investigational: biliopancreatic diversion or bypass without duodenal switch; Billroth II mini‑bypass; laparoscopic gastric plication (CPT 43843); long‑limb gastric bypass (>150 cm); SADI‑S (single anastomosis duodenoileal bypass with sleeve gastrectomy); two‑stage bariatric procedures (e.g., staged BPD), vagus nerve blocking devices; and endoscopic procedures used as primary or revision bariatric therapy including endoscopic sleeve gastroplasty (ESG), StomaphyX, Apollo OverStitch, intragastric balloons (Orbera, ReShape, Obalon, Spatz3), TransPyloric Shuttle, ROSE, AspireAssist, TORe, and endoscopically placed duodenal‑jejunal liners (EndoBarrier).N/A

Adult selection criteria

Covered when ALL of the following are met

BMI threshold: BMI >=40 kg/m2 OR BMI >=35 kg/m2 with at least one clinically significant obesity‑related disease (examples include diabetes, obstructive sleep apnea, coronary artery disease, uncontrolled hypertension) that is not controlled by best‑practice medical management.see node text

No evidence‑based definition for 'clinically significant' is provided; clinical judgment and documentation required.

Conservative management: Documented failure to respond to conservative measures for weight reduction prior to consideration of bariatric surgery; practitioner review of these attempts is required and some centers may require active participation in a formal weight‑reduction program with documented weight, diet, and exercise records.documented attempts

Timing, intensity, and duration of nonsurgical attempts are not standardized in evidence.

Population-specific BMI considerations

Ethnicity-specific thresholds: BMI thresholds do not apply uniformly across all populations; clinical obesity in many Asian populations is identified at BMI >=25 kg/m2 and lower BMI thresholds are recommended for South, Southeast, and East Asian adults.lower than standard BMI

Apply adjusted BMI thresholds for Asian individuals where guideline or labeling indicates.

Adolescent considerations

Adolescent selection: Guidelines for adolescents vary; weight‑based criteria generally parallel adults (examples range from BMI >=35 kg/m2 with comorbidities to BMI >=50 kg/m2). In addition to BMI, emphasize developmental maturity, psychosocial readiness, informed consent, and facility/team experience in pediatric care. Device labeling (e.g., adjustable gastric band) and guideline recommendations may restrict certain procedures for <18 years.varies

Procedure choice in adolescents may differ from adults and some procedures (e.g., BPD) may be discouraged by certain guidelines due to long‑term nutritional risk.

Adults with Class III Obesity

Covered when ALL of the following are met for adults with Class III obesity:

Adults Class III coverage: Adults (>=18 years) with BMI >=40 kg/m2 who receive bariatric surgery (procedures such as Roux‑en‑Y gastric bypass, laparoscopic adjustable gastric banding, sleeve gastrectomy, or biliopancreatic diversion with duodenal switch) have sufficient evidence supporting improved net health outcomes including substantial weight loss and improvements in mortality and comorbidities.BMI >=40 kg/m2

Evidence sources include RCTs, observational studies, and systematic reviews (e.g., SOS study) demonstrating benefit.

Adults with Class II Obesity

Covered when ALL of the following are met for adults with Class II obesity:

Adults Class II coverage: Adults (>=18 years) with BMI 35.0–39.9 kg/m2 who receive bariatric surgery (Roux‑en‑Y gastric bypass, laparoscopic adjustable gastric banding, sleeve gastrectomy, or biliopancreatic diversion with duodenal switch) have evidence supporting improved net health outcomes, including greater weight loss and improvements in diabetes and cardiovascular risk factors compared to nonsurgical therapy.BMI 35.0–39.9 kg/m2

Evidence includes nonrandomized comparative studies and meta‑analyses of RCTs.

Adults with Class I Obesity and Type 2 Diabetes

Covered with criteria for adults with Class I obesity and Type 2 diabetes:

Adults Class I with T2D: Adults with BMI 30.0–34.9 kg/m2 who have Type 2 diabetes that is inadequately controlled with optimal medical therapy may be considered for bariatric surgery; systematic reviews and RCTs show higher rates of diabetes remission compared with medical therapy though overall evidence quality is low to very low.BMI 30.0–34.9 kg/m2 + T2D

Balance potential glycemic benefits against short‑term surgical risks; objective documentation of inadequate glycemic control (e.g., HbA1c >=7%) required.

Adults with BMI <35 kg/m2 without T2D

Not sufficiently supported (insufficient evidence):

Adults BMI <35 without T2D: Adults with BMI <35 kg/m2 who do not have Type 2 diabetes — evidence is insufficient to determine the long‑term risk–benefit of bariatric surgery for this population and bariatric surgery is considered not medically necessary in this context.BMI <35 kg/m2 without T2D

Few small trials and limited observational data exist; not routinely supported.

Revision Bariatric Surgery

Covered when ALL of the following are met for revision bariatric surgery:

Revision bariatric surgery is considered medically necessary when indicated to correct complications or to address failure of the primary procedure, supported by systematic reviews, case series, and registry data showing acceptable complication rates and improvement in outcomes.N/A

Large analyses report acceptable serious complication rates (e.g., 7.2% for conversion to RYGB) with no difference in short‑term mortality compared to primary procedures; documentation of indication and prior compliance required.

Adolescents with Obesity

Covered with restrictions for adolescents:

Adolescents with severe obesity: Adolescents treated with bariatric surgery (RYGB, LAGB, sleeve gastrectomy) can achieve significant weight loss and reduction in comorbidities; surgery is generally reserved for individuals with severe comorbidities or very high BMI (commonly BMI >50 kg/m2) and requires assessment of developmental maturity, psychosocial readiness, and ability to provide informed consent.adolescent BMI criteria per guidelines

Multidisciplinary evaluation and specialized pediatric center experience recommended; procedure choice may differ from adults.

Preadolescent Children with Obesity

Not covered/insufficient evidence for preadolescents:

Preadolescent children: There are no studies focused solely on preadolescent children; evidence is insufficient to determine net health benefit for bariatric surgery in preadolescents and it is not routinely supported outside of specialized contexts.preadolescent age group

Some cohort data in specialized centers exist but further comparative studies are required.

Hiatal Hernia Repair with Bariatric Surgery

Covered when ALL of the following are met regarding hiatal hernia repair:

Hiatal hernia repair with bariatric surgery: When a preoperative diagnosis of hiatal hernia is present, repair of the hiatal hernia at the time of sleeve gastrectomy is associated with improved GERD remission and fewer complications compared with sleeve gastrectomy alone and is considered medically necessary when clinical indications exist preoperatively.preoperative diagnosis of hiatal hernia

No evidence supports routine repair for incidental hiatal hernia without preoperative diagnosis.

Esophagogastroduodenoscopy (EGD) with Bariatric Surgery

EGD use — evidence limited:

Preoperative EGD: Preoperative esophagogastroduodenoscopy (EGD) can detect findings that alter operative management (e.g., malignancy, large hiatal hernia, peptic ulcer, H. pylori) but systematic reviews show only about one‑fifth of patients have EGD findings that alter management; routine universal preoperative EGD is of uncertain benefit.N/A

Surgeon discretion and guideline statements (ASMBS) inform use; evidence insufficient to support routine intraoperative or postoperative EGD universally.

Adult metabolic/bariatric surgery — guideline indications

Covered when ALL of the following are met (guideline-aligned indications):

Adult indication set: 1) Patient meets guideline BMI thresholds (e.g., BMI >=40 kg/m2, or BMI >=35 kg/m2 with one or more severe obesity‑related comorbidities). 2) For patients with Type 2 diabetes, consider surgery at BMI >=30 kg/m2; patients with BMI 30.0–34.9 kg/m2 and T2D with inadequate control despite medical therapy may be considered. 3) Procedure selection should be individualized to patient goals, comorbidities, and surgical risk, with laparoscopic approaches preferred when appropriate.see BMI thresholds

These statements synthesize recommendations from ASMBS, AACE/ACE, and joint guideline updates.

Pediatric/adolescent metabolic/bariatric surgery — guideline indications

Pediatric/adolescent criteria (guideline-based):

Adolescent evaluation criteria: 1) Age and physiologic maturity: adolescents >=13 years should be referred for evaluation; many recommendations use physiologic maturity (Tanner stage IV or ~95% adult height by bone age) when applied. 2) BMI criteria: Class 2 obesity (>=35 kg/m2 or >=120% of the 95th percentile for age/sex with comorbidity) or Class 3 obesity (>=40 kg/m2 or >=140% of the 95th percentile). 3) Presence of serious obesity‑related comorbidities (e.g., T2D, moderate/severe OSA with AHI >=15, NASH, pseudotumor cerebri) influences candidacy. 4) Contraindications include untreated substance abuse, current eating disorder, planned pregnancy, or inability to adhere to postoperative recommendations. 5) Preoperative multidisciplinary screening should include nutritional deficiency assessment (notably vitamin B1) and psychosocial evaluation.see adolescent BMI thresholds

Guidance synthesized from AAP, ASMBS, and Endocrine Society statements.

Pediatric/adolescent surgical indications and prerequisites

Professional society recommendations for bariatric/metabolic surgery in children/adolescents

ASMBS recommendation: ASMBS recommends considering metabolic/bariatric surgery for children and adolescents with BMI >120% of the 95th percentile plus a major comorbidity, or BMI >140% of the 95th percentile after multidisciplinary evaluation at a specialty center; Tanner stage or bone age should not be mandatory barriers to referral.BMI criteria per ASMBS

Emphasizes early referral to multidisciplinary centers and individualized evaluation.

Strong pediatric indications (examples): Strong indications include Type 2 diabetes, moderate/severe obstructive sleep apnea (AHI >=15), nonalcoholic steatohepatitis, and pseudotumor cerebri.clinical comorbidities

From ASMBS pediatric guidance on comorbidities warranting surgery consideration.

Endocrine Society pediatric considerations:

EGD pre/postoperative recommendations

Endoscopic evaluation recommendations

Preoperative EGD: Perform preoperative EGD to detect conditions that may contraindicate or alter the planned bariatric procedure (e.g., malignancy, large hiatal hernia, peptic ulcer disease, H. pylori) and to assess distal stomach anatomy that may affect procedure choice.N/A

ASMBS supports preoperative EGD at surgeon discretion; EGD findings alter management in a minority of patients.

Postoperative EGD surveillance: Consider postoperative EGD for patients with gastrointestinal symptoms; for sleeve gastrectomy, ASMBS suggests consideration of EGD approximately 2–3 years postoperatively even if asymptomatic with subsequent longer‑term surveillance as indicated.time‑based suggestion

These are position‑statement suggestions and not universally established standards of care.

Device labeling and safety monitoring

Device-related coverage and safety considerations

FDA-labeled device use: Authorization for implantable bariatric devices should align with FDA‑labeled indications and limitations (for example, intragastric balloons labeled for use in adults with BMI 30–40 kg/m2 and maximum placement durations such as 6 months).device labeling

Document patient counseling and adherence to device‑specific labeling to support authorization.

Safety monitoring for intragastric balloons: Providers must monitor for known serious adverse events associated with intragastric balloons (spontaneous overinflation, acute pancreatitis, GI obstruction, perforation, and rare deaths) and counsel patients on symptoms requiring urgent evaluation; early removal may be necessary for complications.known adverse events

Based on FDA safety communications (2017–2020).

Medicare National Coverage Determination

Medicare coverage stance

Medicare coverage criteria: Medicare covers open and laparoscopic Roux‑en‑Y gastric bypass (RYGB), laparoscopic adjustable gastric banding (LAGB), and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) for beneficiaries with BMI >35 kg/m2, at least one obesity‑related comorbidity, and prior unsuccessful medical treatment for obesity. Other procedures listed in the NCD are noncovered for Medicare beneficiaries.Medicare NCD requirements

The NCD explicitly lists several noncovered procedures (e.g., open/laparoscopic vertical banded gastroplasty; open/laparoscopic sleeve gastrectomy; open adjustable gastric banding).

Notable documented criteria and revisions

Not all full selection criteria are present in these chunks; below are specific criteria and modifications documented here.

Preoperative participation: Individual must have participated in a physician‑supervised weight loss program for at least 3 continuous months within the past 12 months (policy changed from prior 6‑month requirement).3 months

Change documented in policy history (05/01/21 update).

Reoperation for inadequate weight loss: Reoperation may be considered medically necessary when the initial bariatric surgery failed to achieve adequate weight loss, defined as failure to lose >=50% of excess body weight OR failure to achieve >=20% total weight loss.>=50% EWL or >=20% TWL

Definition added in 2025 policy revisions.

Asian BMI threshold: An added BMI threshold specific to the Asian population has been incorporated as a medically necessary selection criterion (lower BMI cutoffs noted in policy and guideline summaries).

Vertical-banded gastroplasty (VBG; CPT 43842) is considered not medically necessary due to historically high rates of complications, revisions, and reoperations. The policy notes VBG has largely been replaced in the U.S. by other procedures (e.g., laparoscopic adjustable gastric banding or sleeve gastrectomy) and is not an endorsed procedure by specialty societies.

The policy lists a broader set of procedures as investigational (and therefore not supported for routine coverage), including various novel surgical configurations and many endoscopic approaches; these investigational items may be billed using unlisted procedure codes when reported (e.g., 43659, 43999, 44238, 44799).

Adjustable gastric banding devices (LAP-BAND, REALIZE) are approved for use in selected adults but are not FDA-approved for individuals younger than 18 years. The policy highlights that some guidelines do not recommend certain malabsorptive procedures (e.g., biliopancreatic diversion) in adolescents because of concerns about long-term nutritional deficiencies.

When evaluating adolescents, the policy emphasizes procedure selection may differ from adults and that device labeling and long-term nutritional risks should inform candidacy and consent.

Vertical-banded gastroplasty (VBG) is described as largely no longer performed in the U.S. because of high long-term revision and reoperation rates. The policy documents that VBG has been superseded by other restrictive procedures and is not included among procedures endorsed by the American Society for Metabolic and Bariatric Surgery.

The policy states bariatric surgery for adults with BMI <35 kg/m2 who do not have type 2 diabetes is not supported due to insufficient evidence on long-term net health benefit. Similarly, evidence is insufficient to support routine bariatric surgery for preadolescent children; available cohort data are limited and further comparative studies are required.

For preadolescent cases, even where small series suggest potential benefit at specialized centers, the policy treats the evidence as inadequate to conclude improved net health outcomes and therefore does not routinely support coverage.

The American Academy of Pediatrics (AAP) identifies contraindications for adolescent bariatric surgery that include a medically correctable cause of obesity, untreated or poorly controlled substance abuse, concurrent or planned pregnancy, current eating disorder, or inability to adhere to postoperative recommendations. These contraindications should be considered during preoperative evaluation and when documenting candidacy.

The Medicare National Coverage Determination (NCD) explicitly lists several procedures as noncovered for Medicare beneficiaries (for example, open and laparoscopic vertical-banded gastroplasty and certain sleeve gastrectomy and adjustable banding procedures at the time of the NCD). Providers should consider Medicare NCD rules when determining coverage for beneficiaries.

The policy’s reference section contains systematic reviews, randomized controlled trials, and guideline documents that support the clinical rationale for bariatric procedures. These bibliographic references inform evidence summaries and the policy’s coverage positions.

Policy history dating back to the late 1990s documents shifts in coverage stance for specific procedures as evidence and device labeling have evolved; providers may consult the cited history for context on past changes.

Policy history entries record iterative updates to procedure classifications and coding over time (for example, reclassifying vertical-banded gastroplasty to not medically necessary and updating statements about liver biopsy during obesity surgery). These historical entries explain prior rationale and coding changes that underpin current policy language.

When submitting authorization requests, providers should be aware that historical policy revisions influenced current documentation expectations and coverage definitions.

Repair of a hiatal hernia performed at the time of bariatric surgery is medically necessary only when a preoperative diagnosis with clinical indications is documented. Routine repair in the absence of preoperative indications is considered not medically necessary.

Similarly, routine liver biopsy during obesity surgery is considered not medically necessary unless there are preoperative signs or symptoms of liver disease (for example, elevated liver enzymes or hepatomegaly) documented in the chart.

Multiple specialty society guidelines (AACE/ACE, ASMBS and joint updates) support offering metabolic and bariatric surgery to adults with BMI ≥40 kg/m2, or BMI ≥35 kg/m2 with at least one severe obesity‑related comorbidity. For adults with type 2 diabetes, many guidelines support considering surgery at lower thresholds (e.g., BMI 30–34.9 kg/m2 with inadequate glycemic control despite optimal medical therapy).

These guideline-derived thresholds are the basis for the policy’s coverage criteria and should be documented in prior authorization submissions when applicable.

For adults with Class I obesity (BMI 30–34.9 kg/m2) and type 2 diabetes, randomized trials and meta-analyses show higher rates of diabetes remission with surgery compared with medical therapy; however, the overall evidence strength is lower than for higher-BMI patients, so candidacy requires careful selection and documentation of inadequate glycemic control (e.g., HbA1c ≥7%) despite medical therapy.

Providers should explicitly document attempts at optimal medical and lifestyle therapy and the persistent inadequate glycemic control when seeking authorization under this indication.

The policy lists a number of procedures as investigational (e.g., long-limb gastric bypass >150 cm, single-anastomosis duodenoileal bypass with sleeve gastrectomy [SADI-S], certain endoscopic primary or revision procedures). These investigational procedures are not supported for routine coverage.

The CDC and guideline materials referenced in the policy provide standard BMI class definitions (Class I, II, III) that the policy uses when applying selection thresholds and interpreting eligibility criteria.

Adolescent bariatric surgery criteria vary across guidelines; the policy emphasizes individualized assessment of physiological maturity, psychosocial readiness, and multidisciplinary support. AAP guidance recommends referral for evaluation in adolescents aged ≥13 years with severe obesity (e.g., BMI ≥120% of the 95th percentile).

Procedure choice in adolescents should account for device labeling (some devices lack pediatric approval) and long-term nutritional implications; documentation of informed consent and center capability is required.

Device-specific labeling and FDA PMA indications are important for coverage decisions: for example, intragastric balloons have limited maximum placement durations and defined BMI ranges in their approvals. The policy expects documentation aligning device use with FDA-labeled indications and counseling on device-specific risks.

Medicare’s NCD establishes coverage rules for beneficiaries (e.g., coverage for RYGB, LAGB, BPD/DS in beneficiaries with BMI >35 kg/m2 and comorbidity after unsuccessful medical treatment) and separately lists procedures that Medicare considers noncovered; these rules affect coverage determinations for Medicare members.

Recent policy revisions include a change in the required duration of physician‑supervised weight‑reduction program participation from six months to at least 3 continuous months within the prior 12 months. This is a material change effective per the policy history.

The policy also adds an explicit definition for inadequate weight loss when considering reoperation: failure to lose ≥50% of excess body weight or failure to achieve ≥20% total weight loss, and introduces an added BMI threshold specific to the Asian population as a medically necessary selection criterion effective November 7, 2025.

Coding and Code-Based Criteria

Covered and referenced procedure codesmixed

0813T	Esophagogastroduodenoscopy, flexible, transoral, with volume adjustment of intragastric bariatric balloon (Spatz3)
43290	Esophagogastroduodenoscopy, flexible; transoral; with deployment of intragastric bariatric balloon.
43291	Esophagogastroduodenoscopy, flexible; transoral; with removal of intragastric bariatric balloon(s).
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 laparoscopy procedure, stomach.
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.

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Listed CPT codes (laparoscopic/open gastric procedures, adjustable banding, sleeve, bypass, revisions)CPT

43645	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption.
43659	Unlisted laparoscopy procedure, stomach.
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 (i.e, sleeve gastrectomy).

Listed CPT codes (open gastric procedures, revisions, unlisted)CPT

43842	Gastric restrictive procedure; without gastric bypass, for morbid obesity; vertical-banded gastroplasty.
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).
43846	Gastric restrictive procedure; with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy.
43847	Gastric restrictive procedure; with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption.
43848	Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure).
43886	Gastric restrictive procedure, open; revision of subcutaneous port component only.
43887	Gastric restrictive procedure, open; removal of subcutaneous port component only.
43888	Gastric restrictive procedure; open; removal and replacement of subcutaneous port component only.
43999	Unlisted procedure; stomach.

Other unlisted CPT codesCPT

44238	Unlisted laparoscopy procedure, intestine (except rectum).
44799	Unlisted procedure; small intestine.

HCPCS codes (endoscopic procedures)HCPCS

C9784	Gastric restrictive procedure, endoscopic sleeve gastroplasty, with esophagogastroduodenoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components.
C9785	Endoscopic outlet reduction, gastric pouch application, with endoscopy and intraluminal tube insertion; if performed, including all system and tissue anchoring components.