inv-01: Covered procedures for adults
Covered procedures for adults — Covered when ALL applicable selection criteria are met and procedure is one of the listed covered surgeries.
Biliopancreatic bypass (Scopinaro) with duodenal switch (open 43845 or laparoscopic 43659)
Gastric bypass using a Roux-en-Y anastomosis (open or laparoscopic) (43644, 43645, 43846)
Laparoscopic adjustable gastric banding (e.g., LAP-BAND, REALIZE) (43770)
Sleeve gastrectomy (43775)
Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) (43999)
inv-02: Adults with T2 diabetes and Class I obesity
Adults with T2 diabetes and Class I obesity — Covered when ALL of the following are met
BMI in the class I obesity range (≥30 to 34.9 kg/m2; for Asian individuals ≥27.5 to 32.4 kg/m2)
Documented diagnosis of type 2 diabetes mellitus with inadequate glycemic control (HbA1c ≥7%) despite lifestyle modifications and use of antidiabetic medications
Demonstrated failure of conservative weight-loss measures, including participation in a physician-administered or structured weight reduction program for at least three continuous months within the 12 months before surgery (documentation of weight, dietary program, and physical activity)
Mental health evaluation and clearance by a licensed mental health provider confirming no contraindication to surgery and ability to provide informed consent
Procedure performed by a surgeon with specialized bariatric training at a facility with a comprehensive bariatric program
inv-03: Adolescents (<18 years)
Adolescents (<18 years) — Covered when ALL of the following are met
Health plan contract allows bariatric surgery for persons younger than 18 years of age
Adolescent meets the same individual selection criteria as adults with class II or III obesity (including BMI and comorbidity criteria adjusted for pediatric percentiles where applicable)
Facility and care team experienced in adolescent bariatric care, including psychosocial evaluation and consent processes
Devices used for adjustable gastric banding are FDA-approved for adults only; use in individuals <18 years should follow device labeling and institutional review
inv-04: Revision and reoperation criteria
Revision and reoperation criteria — Revision or conversion procedures may be medically necessary when specified conditions are met
Revision bariatric surgery may be considered medically necessary to address perioperative or late complications from the primary bariatric procedure including band erosion, slippage, leakage, herniation, intractable nausea/vomiting not correctable by adjustment, component malfunction not repairable, non-absorption resulting in hypoglycemia or malnutrition, obstruction, staple-line failure (e.g., gastrogastric fistula), stricture, ulceration
Conversion of sleeve gastrectomy to Roux-en-Y for symptomatic GERD is considered 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 (≥8 weeks daily PPI)
Reoperation or conversion for inadequate weight loss may be considered when previous surgery was ≥2 years prior, there is documentation of compliance with postoperative nutrition and exercise program, failure to achieve adequate weight loss (failure to lose ≥50% excess body weight or <20% total weight loss), and coverage is available under the member's plan
Revision for pouch dilation is considered medically necessary when initial procedure produced weight loss prior to documented pouch dilation and the member has been compliant with nutrition and exercise recommendations
inv-05: COVERAGE CRITERIA
COVERAGE CRITERIA — Covered when ALL of the following are met (selection criteria described in policy text and referenced guidelines)
Individual meets BMI and comorbidity thresholds as specified for adults (class III, class II with comorbidity, or class I with T2D as applicable)
Documentation of failure of conservative measures (see failure of conservative measures group)
Mental health evaluation and clearance
Performed at an experienced bariatric surgery center by a qualified surgeon
Device used must be FDA-approved for the indicated purpose and used according to labeled indications
inv-06: Failure of conservative measures
Failure of conservative measures — AND
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 commercial program (e.g., Weight Watchers) with physician supervision
Evidence of active participation documented in the medical record (weights, dietary program, physical activity)
For adjustable gastric banding, documentation of postoperative compliance with diet and regular bariatric visits is required prior to consideration of a second bariatric procedure
inv-07: Procedure-specific considerations
Procedure-specific considerations — AND
Adjustable gastric banding: device labeling and FDA indications must be followed; banding devices have age limitations per FDA labeling
Gastric bypass: CPT 43846 is for short limb (≤150 cm) Roux-en-Y; long-limb (>150 cm) gastric bypass (43847) is considered investigational
Hiatal hernia repair: repair performed at time of bariatric surgery is covered when a preoperative diagnosis with clinical indications for repair exists; incidental hiatal hernia repair without preoperative indication is not supported
Routine liver biopsy during obesity surgery is not medically necessary in the absence of preoperative signs or symptoms of liver disease (e.g., elevated LFTs, hepatomegaly)
Routine, universal preoperative EGD is not required for all patients; performing EGD should be at the surgeon's discretion and based on symptoms or institutional protocols
inv-08: Adults with Class III Obesity
Adults with Class III Obesity — Covered when ALL of the following are met:
BMI ≥40 kg/m2 (≥37.5 kg/m2 for Asian individuals)
Failure of conservative weight-loss measures as documented
Mental health evaluation and clearance
Surgery performed at an accredited bariatric center by an experienced surgeon
inv-09: Adults with Class II Obesity
Adults with Class II Obesity — Covered when ALL of the following are met:
BMI 35.0–39.9 kg/m2 (or ≥32.5–37.4 kg/m2 for Asian individuals)
At least ONE obesity-related comorbid condition (e.g., established coronary heart disease, uncontrolled or refractory hypertension despite ≥2 medications, peripheral arterial disease, symptomatic carotid disease, type 2 diabetes, moderate–severe OSA documented by sleep study)
Failure of conservative weight-loss measures as documented
Mental health evaluation and clearance
inv-10: Adults with Class I Obesity and Type 2 Diabetes
Adults with Class I Obesity and Type 2 Diabetes — Covered when ALL of the following are met:
BMI 30.0–34.9 kg/m2 (or ≥27.5–32.4 kg/m2 for Asian individuals)
Documented type 2 diabetes with inadequate glycemic control (HbA1c ≥7%) despite lifestyle and medical therapy
Failure of conservative weight-loss measures as documented
Mental health evaluation and clearance
inv-11: Adults with BMI <35 kg/m2 without T2D
Adults with BMI <35 kg/m2 without T2D — Not routinely covered / insufficient evidence
Bariatric surgery is considered not medically necessary for individuals with BMI <35 kg/m2 who do not have type 2 diabetes, and for all individuals with BMI <30 kg/m2 (except as otherwise noted for Asian populations)
inv-12: Revision Bariatric Surgery
Revision Bariatric Surgery — Covered when ALL of the following are met:
Indication is a complication of the primary procedure (e.g., erosion, slippage, obstruction, fistula, stricture, malnutrition) or documented inadequate weight loss meeting policy thresholds
Sufficient documentation of prior procedure details and current problem, including objective testing (endoscopy, imaging) as appropriate
For reoperation due to inadequate weight loss, previous surgery occurred ≥2 years prior and there is documented compliance with postoperative care and nutrition
inv-13: Adolescents with Obesity
Adolescents with Obesity — Covered when ALL of the following are met:
Meet pediatric-adapted BMI thresholds and comorbidity criteria (per guideline recommendations)
Demonstrate developmental maturity and psychosocial readiness; psychological evaluation confirming family stability and ability to adhere to postoperative care
Evaluation and treatment performed at specialized pediatric bariatric center with multidisciplinary team
Device labeling: adjustable gastric band devices are not FDA-approved for individuals younger than 18 years — device use must comply with regulatory labeling and institutional policies
inv-14: Preadolescent Children with Obesity
Preadolescent Children with Obesity — Not routinely covered / insufficient evidence
Insufficient evidence to support routine use of bariatric surgery in preadolescent children; considered investigational except in exceptional circumstances at specialized centers and after multidisciplinary review
inv-15: Hiatal Hernia Repair with Bariatric Surgery
Hiatal Hernia Repair with Bariatric Surgery — Covered when ALL of the following are met:
Preoperative diagnosis of hiatal hernia with clinical indications for repair documented
Repair performed at time of bariatric surgery in individuals meeting preoperative indication
Incidental hiatal hernia discovered intraoperatively without preoperative indication: routine repair is not supported by evidence
inv-16: Coverage criteria for bariatric surgery and adjunct procedures
Coverage criteria for bariatric surgery and adjunct procedures — Covered when ALL of the following are met
Medical necessity criteria for the primary bariatric procedure are satisfied (see inv-05 through inv-14)
Any adjunct procedures (e.g., cholecystectomy when indicated) are supported by preoperative diagnosis and contemporaneous medical need
Device use follows FDA approval and labeled indications
inv-17: Adolescent bariatric surgery indications
Adolescent bariatric surgery indications — Society and guideline recommendations for adolescent bariatric surgery (selection guidance):
Use pediatric-adapted BMI thresholds (e.g., BMI ≥120% of 95th percentile with major comorbidity, or ≥140% of 95th percentile) and consider comorbid conditions such as T2D, moderate–severe OSA, NASH, IIH, SCFE, and impaired quality of life
Assess developmental maturity, Tanner stage where applicable, and psychosocial readiness; psychological evaluation of family stability and ability to adhere to follow-up care
Refer adolescents ≥13 years with severe obesity for evaluation at multidisciplinary pediatric metabolic and bariatric centers per AAP guidance
inv-18: Perioperative evaluation and hiatal hernia/endoscopy
Perioperative evaluation and hiatal hernia/endoscopy — Perioperative evaluation and procedure-specific considerations:
Preoperative endoscopy (EGD) may be performed at surgeon discretion; routine universal preoperative EGD is not mandated due to limited impact on management in many patients
Repair of preoperatively diagnosed hiatal hernia is supported; incidental repair without preoperative indication is not routinely supported
Perioperative assessment should document comorbidities, nutritional status, and need for adjunct procedures
inv-19: Device regulatory/safety criteria
Device regulatory/safety criteria
Any device used for bariatric surgery must be FDA-approved for the intended bariatric indication and used according to the labeled indications and age limitations
Adjustable gastric band devices (e.g., LAP-BAND, REALIZE) have specific FDA-labeled indications and age considerations; use must conform to labeling
Intragastric balloons, aspiration systems, and other endoluminal devices have specific labeled indications, maximum placement durations, and patient selection criteria (see FDA PMA labeling)
Providers must be aware of FDA safety communications (e.g., intragastric balloon overinflation, risk of acute pancreatitis, reported deaths) and monitor patients per recommendations; inform patients of potential device-specific risks and required monitoring
Device use outside labeled indications (off-label) requires clear documentation of rationale and may not meet coverage criteria unless supported by evidence and payer authorization
inv-20: Key updated coverage criteria (extract)
Key updated coverage criteria (extract) — Policy includes medical necessity criteria for primary bariatric surgery, revision surgery, and reoperation; notable updated items include:
Addition of SADI-S to list of procedures considered medically necessary (effective 04/01/26)
Clarified Asian-specific BMI thresholds for selection criteria
Refinements to reoperation criteria for inadequate weight loss, including explicit weight-loss failure thresholds (≥50% EBW or <20% TWL)