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SelectHealth Clinical/Medical Policy — General Surgery: Coverage Criteria

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SelectHealth clinical/medical policy brief listing General Surgery policies and coverage criteria applicable to SelectHealth Commercial, Medicare, and Medicaid plans; guides provider coverage requests.

Policy Summary

PayerSelectHealth

PolicyGeneral Surgery — Coverage Criteria (clinical/medical policy)

Policy CodePolicy N/A

Change TypeMaterial revisions to Commercial Plan criteria and added liposuction-for-lymphedema section

Effective DateN/A

Last ReviewJun 7, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document that the member meets all listed medical necessity criteria, including required assessments and conservative therapy trials.

SourceLink

POLICY UPDATE CHANGES

For Commercial Plan Policy, added criterion #3: AFT is also indicated in breast augmentation for patients who have been treated for contralateral breast cancer and are seeking a symmetry procedure.

For Commercial Plan Policy, modified requirements in criteria #7 to specify documentation of a preoperative nutritional assessment within one year of surgery including weight history, assessment of maladaptive eating disorders, and evaluation of micronutrient deficiencies.

For Commercial Plan Policy, modified requirements in criteria #7 including removal of the micronutrient deficiencies evaluation requirement.

For Commercial Plan Policy, added new criteria section #III for consideration of coverage of liposuction for lymphedema.

3plans referenced

Coverage Criteria and Medical Necessity

Athletic Pubalgia (Sport's Hernia) Repair

Select Health coverage stance:

Primary coverage rule: Select Health does NOT cover athletic pubalgia (sport's hernia) repair because the condition is ill-defined and there is lack of consensus regarding patient selection and surgical approach; the procedure is considered experimental/investigational under plan definitions.

Applies to Commercial Plan and CHIP per policy #487.

Covered Indications

Covered when ANY of the following apply:

Covered Indications: 1) Surgical correction following a medically necessary mastectomy or medically necessary lumpectomy that resulted in a significant deformity; 2) Repair of significant/obvious breast asymmetry directly related to trauma (deformity/asymmetry must be apparent after the trauma/injury); 3) Autologous fat transfer (AFT) for breast augmentation in patients treated for contralateral breast cancer who are seeking a symmetry procedure (provides smaller volume augmentation with broader distribution than implants).

Commercial Plan and CHIP indications per policy #507.

Medical Necessity Criteria

Covered when ALL of the following are met (separate criteria for adolescents and adults):

Adolescent criteria (ages 13-18): Patient aged 13-18 AND (BMI > 40 OR BMI > 35 with at least one inadequately controlled obesity-related disease) AND surgery performed at an MBSAQIP-accredited or pending-accreditation facility (or a facility actively pursuing accreditation under proctoring) AND 1-month tobacco abstinence immediately prior to surgery AND evidence that reasonable non-surgical alternatives were discussed and attempted AND documentation within 6 months of a multidisciplinary evaluation including nutritional assessment and psychological assessment when indicated with pediatric/adolescent-trained behavioral health provider, demonstrating mature decision-making, assent, and adequate family/social support.

Qualifying comorbidities enumerated in policy (e.g., type 2 diabetes, hypertension, dyslipidemia, moderate-to-severe OSA, MASLD/MASH, cryptogenic cirrhosis, cardiovascular disease, pseudotumor cerebri, refractory GERD, severe osteoarthritis).

Adult criteria (>=18 years): Patient aged >=18 AND (BMI > 40 OR BMI > 35 with at least one inadequately controlled obesity-related disease; BMI thresholds reduced by 2.5 kg/m2 for patients of Asian descent) AND surgery performed at an MBSAQIP-accredited or pending-accreditation facility (or a facility actively pursuing accreditation under proctoring) AND 1-month tobacco abstinence immediately prior to surgery AND evidence that reasonable non-surgical alternatives were discussed and attempted AND documentation within 6 months of a multidisciplinary evaluation including nutritional assessment and psychological assessment when indicated, with active mental health care proximate to surgery.

Same qualifying comorbidities as adolescent criteria; mild-to-moderate depression is not a contraindication.

Coverage Limits and Exceptions

Coverage limits and special-case allowances:

Lifetime limit: Bariatric surgery coverage is limited to one lifetime procedure, except: individuals with initial BMI > 60 may receive biliopancreatic bypass with duodenal switch after a prior sleeve gastrectomy, and individuals who previously had laparoscopic gastric banding may have additional procedures; these additional procedures are not considered a revision of the initial procedure. Revisional surgery is covered only for complications of prior bariatric surgery; conversion of sleeve to Roux-en-Y is allowed for medically refractory GERD/dysphagia after failure of maximal medical therapy.

Members must not have other severe comorbidities that increase surgical risk.

General coverage rationale and comparative efficacy

Clinical evidence summary and procedural considerations:

Comparative efficacy and evidence summary: Policy summarizes comparative evidence across bariatric procedures: Roux-en-Y is considered the gold standard; biliopancreatic diversion/duodenal switch yields greater excess weight loss but higher long-term metabolic/nutritional risk; long-limb Roux-en-Y may increase weight loss but with more nutritional disturbances; sleeve gastrectomy shows promising short-term outcomes but limited long-term data; obsolete procedures (jejunoileal bypass, gastric wrapping, Garren gastric bubble) have been abandoned. Evidence quality and long-term data vary by procedure.

Summarized from multiple systematic reviews and primary studies cited in the policy.

Medical necessity criteria

Covered when ALL of the following are met

Cryoablation coverage criteria: 1) Patient has an extra‑abdominal desmoid tumor that is symptomatic, progressive, or unresectable; AND 2) Disease has progressed after failure of at least two lines of medical therapy; AND 3) Tumor characteristics (size, location) are suitable for cryoablation (small-to-moderate size, not adjacent to critical structures where complete ablation would risk nerves or vital tissues); AND 4) Expected benefit (disease control, pain relief, functional improvement) outweighs procedural risk.see node text

Select Health covers cryoablation for desmoid tumors as medically necessary per policy language.

Commercial plan coverage criteria

Covered when ALL of the following are met:

Commercial coverage criteria (gastric diversion): 1) BMI > 35 OR BMI < 35 with prior sleeve gastrectomy; AND 2) Daily reflux symptoms despite maximum PPI therapy; AND 3) Objective evidence of reflux by 24–48 hour ambulatory pH probe (DeMeester score > 14.7) OR EGD documenting esophagitis grade C/D or Barrett's esophagus; AND 4) Documentation of failed medically managed weight loss.DeMeester score > 14.7

Applies to Select Health commercial plan coverage for gastric diversion procedures.

General criteria for gender affirmation surgery (Commercial/CHIP)

Covered when ALL of the following are met

General GAMST surgical criteria: 1) Member must be age 18 or older; AND 2) Healthcare professionals assessing transgender and gender diverse individuals meet WPATH SOC-8 minimum requirements; AND 3) HCPs consult with other professionals from different disciplines; AND 4) Gender dysphoria is diagnosed and considered marked and sustained (per DSM-5-TR/WPATH SOC-8, minimum duration 6 months); AND 5) Other possible explanations for gender incongruence have been excluded; AND 6) Impacts of surgical treatment on mental and physical health have been discussed; AND 7) Ensure capacity to consent; AND 8) Social transitioning has been considered and discussed.age >= 18; duration >= 6 months

Applies to commercial and CHIP plans where GAMST is covered per policy #386 and related policies.

Breast removal requirements

Covered when ALL of the following are met

Mastectomy (breast removal) requirements: 1) Member must be age 18 or older; AND 2) Single letter of referral from a qualified healthcare professional; AND 3) Surgeon has assessed risk factors associated with breast cancer.

Specific referral letter format referenced in Appendix C of the policy.

Breast augmentation requirements

Covered when ALL of the following are met

Breast augmentation requirements (implants/lipofilling): 1) Member must be age 18 or older; AND 2) Single letter of referral from a qualified healthcare professional; AND 3) Surgeon has assessed risk factors associated with breast cancer. Note: More than one breast augmentation (excluding fat grafting) is considered cosmetic and not medically necessary; replacement of medically necessary implants is not excluded.

Policy notes that hormone therapy timing is not mandated but may be recommended for surgical results.

Gonadectomy and genital reconstructive surgery requirements

Covered when ALL of the following are met

Gonadectomy requirements: 1) Member must be age 18 or older; AND 2) One referral letter from a qualified healthcare professional; AND 3) Six months of continuous hormone therapy as appropriate to the member's gender goals (unless contraindicated or not desired); AND 4) Reproductive effects, including loss of fertility and preservation options, have been discussed and pursued if desired prior to irreversible intervention.6 months

Applies to hysterectomy/oophorectomy or orchiectomy per policy #386.

Genital reconstructive surgery requirements: 1) Member must be age 18 or older; AND 2) One referral letter from a qualified healthcare professional; AND 3) Six months of continuous hormone therapy as appropriate to the member's gender goals (unless contraindicated or not desired); AND 4) Reproductive effects, including loss of fertility and preservation options, have been discussed and pursued if desired prior to irreversible intervention.6 months

Includes procedures such as vaginoplasty, phalloplasty, metoidioplasty, urethroplasty, scrotoplasty, and prosthesis placement.

General coverage stance

Covered when consistent with clinical indications and member benefits:

General coverage stance: Gender-affirming medical and surgical treatments are part of care for individuals with gender dysphoria and may be covered when supported by clinical documentation consistent with WPATH SOC-8 and when member benefits permit.

Care should be multidisciplinary and patient-centered per policy guidance.

Coverage criteria for surgical treatment

Covered when ALL of the following are met

Colorado surgical coverage criteria: Member is enrolled on a SelectHealth commercial plan filed for use in Colorado AND member is at least 18 years of age for surgical treatment AND member has a diagnosis of gender dysphoria as defined by DSM-5-TR with at least 6 months duration (interpreted as 'marked and sustained' per WPATH SOC-8).age >= 18; duration >= 6 months

For Colorado-based plans the policy lists specific procedures that are covered; other procedures require meeting policy #386 criteria.

List of explicitly covered procedures

Procedures specifically listed as covered for Colorado commercial plans:

Listed procedures (non-exhaustive): Includes hormone therapy; genital and non-genital surgical procedures; blepharoplasty; face/forehead/neck tightening; facial bone remodeling; genioplasty; rhytidectomy; implants; lip procedures; mandibular procedures; orbital recontouring; rhinoplasty; laser/electrolysis hair removal; breast/chest augmentation, reduction, construction; dilator; gluteal augmentation; modified radical mastectomy; lipofilling; and others as listed in the Colorado-specific policy.

For procedures not listed, members must meet policy #386 criteria.

Coverage criteria for gynecomastia surgery

Covered when ONE of the following is met:

Primary coverage pathways: Either: (A) Klinefelter's syndrome; OR (B) Persistent gynecomastia meeting duration criteria and ALL subsequent requirements.

See follow-up nodes for pathway B requirements.

Persistent gynecomastia pathway (B) - prerequisite duration: Pubertal-onset gynecomastia persisted ≥2 years OR post-pubertal onset persisted ≥1 year, AND ALL of the following:

Required findings: Glandular breast tissue documented on physical exam and/or by mammography confirming true gynecomastia.

Severity: Gynecomastia classified as Grade II or greater per ASPS-adapted classification.

Immediate Lymphatic Reconstruction

Immediate Lymphatic Reconstruction — Select Health covers immediate lymphovenous bypass when A or B is met

Immediate ILR Indications

A. Breast cancer scenario: 1) Surgical plan includes axillary lymph node dissection (or cross-over sentinel node) for breast cancer at the time of initial cancer resection OR planned radiation therapy OR planned mastectomy; AND 2) Attestation that the individual has demonstrated ability to tolerate post-surgical compression therapy and physical therapy sessions per the treating lymphedema provider.
B. Other cancers: 1) Surgical plan includes lymph node dissection at the time of initial cancer resection or a cross-over sentinel node that would drain an arm or leg; AND 2) Attestation that the individual has demonstrated ability to tolerate post-surgical compression therapy and physical therapy sessions per treating lymphedema provider.

Delayed Lymphatic Reconstruction

Delayed Lymphatic Reconstruction — Select Health covers lymphovenous bypass when ALL of the following are met

Delayed ILR Eligibility (overall): All of A–D must be met.

A. Diagnostic criteria: 1) At least one sign (pitting or non-pitting edema; fibrosis; limited mobility from swelling) AND one symptom (heaviness, achiness, pain, tightness, numbness/tingling, not fitting into clothing, or fatigue) consistent with lymphedema; AND 2) Diagnosis of ISL stage ≥ I.

B. Positive quantitative measurement (unilateral disease): At least one of: lymphoscintigraphy with ≥1-hour delayed transit to first-level lymph nodes or dermal backflow; OR ICG imaging demonstrating obstruction with reticular or stardust pattern; OR MRI lymphangiography demonstrating obstruction or dermal backflow.

C. Lymphovenous bypass eligibility criteria: 1) BMI ≤ 35; AND 2) Engaged and maintained compliance with conservative lymphedema treatment by a certified lymphedema therapist for ≥1 month including compression therapy and at least one modality (manual lymphatic drainage, complete decongestive therapy, pneumatic compression pump, or targeted exercises); AND 3) Demonstrated ability to tolerate post-surgical compression therapy and physical therapy sessions per treating provider.

Liposuction Coverage Criteria

Liposuction for lymphedema — covered when ALL of the following are met

Liposuction criteria: 1) Member has unilateral non-pitting ISL Stage 2 or 3 lymphedema; AND 2) Limb volume difference > 25%; AND 3) Documented physical functional impairment; AND 4) Previously failed conservative therapy including compression therapy and lymphedema pump therapy.limb volume difference > 25%

Stage definitions provided in policy.

Liposuction for lymphedema - Covered criteria

Covered when ALL of the following are met:

Liposuction for lymphedema - Covered criteria: 1) Unilateral non-pitting ISL Stage 2 or 3 lymphedema; AND 2) Limb volume difference in excess of 25%; AND 3) Physical functional impairment; AND 4) Previously failed conservative therapy including both compression therapy and lymphedema pump therapy.> 25%

New criteria section III for liposuction for lymphedema added per revision history.

Lipedema of extremities coverage criteria

Covered when ALL of the following are met

Facility and diagnostic documentation: Procedure will be performed in a hospital or ambulatory surgical center; AND diagnosis of lipedema documented by clinical exam and photography showing typical bilateral symmetric thickened subcutaneous fat in affected extremities.

Diagnostic features: Clinical findings include pain and/or hypersensitivity in affected areas; history of easy bruising in affected areas; Stemmer's sign negative; absence of pitting edema unless comorbid lymphedema.

Functional impairment and conservative therapy: Documentation of significant physical functional impairment (e.g., difficulty ambulating or performing activities of daily living) or medical complications (recurrent cellulitis or skin ulcerations); AND failed response to six or more consecutive months of conservative management (compression garments, non-calibrated segmental lymphedema pump therapy, manual therapy); AND lack of improvement with weight loss and with limb elevation.6 months

Lipedema of trunk coverage criteria

Trunk lipedema covered when ALL of the following are met

Facility and diagnostic documentation (trunk): Procedure performed in a hospital or ambulatory surgical center; AND diagnosis documented by clinical exam and photography showing pain/hypersensitivity, easy bruising, and tenderness/nodularity (dimpled or 'orange peel' texture) of trunk adipose deposits.

Therapy failure (trunk): Failed response to six or more consecutive months of conservative management; AND lack of improvement with weight loss.6 months

Procedure and Billing Codes

Not covered: Investigational/Experimental/Unproven for this indication CPT CODESCPTNot Covered

49659	Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy
49999	Unlisted procedure, abdomen, peritoneum and omentum
49650	Laparoscopy, surgical, repair initial inguinal hernia

HCPCS CodesHCPCS

No codes listed

CPT Codes (covered for listed conditions)CPTCovered

19499

Unlisted procedure, breast

HCPCS CodesHCPCS

No codes listed

Covered and Not Covered Procedures (no CPT/HCPCS codes listed in provided text)mixed

No codes listed

Covered CPT CodesCPTCovered

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
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)
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

Covered revision CPT CodesCPTCovered

43848	Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)
43860	Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy
43865	Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy

Not covered / Investigational CPT CodesCPTNot Covered

43659	Unlisted laparoscopy procedure, stomach
43770	Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g., 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
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
43847	Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption
43886	Gastric restrictive procedure, open; revision of subcutaneous port component only
43887	Gastric restrictive procedure, open; removal of subcutaneous port component only

1–10 of 13

1/2

HCPCS CodesHCPCS

S2083

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

CPT CODESCPT

20999

Unlisted procedure, musculoskeletal system, general

HCPCS CODESHCPCS

C2618

Probe/needle, cryoablation

CPT CODESCPTCovered

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

Listed CPT CodesCPT

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

Covered/Listed CPT CodesCPTCovered

00402	Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; reconstructive procedures on breast (eg, reduction or augmentation mammoplasty, muscle flaps).
00926	Anesthesia for procedures on male genitalia (including open urethral procedures); radical orchiectomy, inguinal.
11980	Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin).
14040	Adjacent tissue transfer or rearrangement; defect 10 sq cm or less.
14041	Adjacent tissue transfer or rearrangement; defect 10.1 sq cm to 30.0 sq cm.
14301	Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm.
15100-15101	Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, + each additional 1%.
15120	Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet; first 100 sq cm or less.
15271	Application of skin substitute graft to trunk, arms, legs; first 25 sq cm or less.
15272	Each additional 25 sq cm wound surface area.

1–10 of 46

1/5

HCPCS CodesHCPCSCovered

C1789	Prosthesis, breast (implantable).
C1813	Prosthesis, penile, inflatable.
L8600	Implantable breast prosthesis, silicone or equal.
S0189	Testosterone pellet, 75 mg.

Not Covered for the indications listed aboveCPTNot Covered

19303	Mastectomy, simple, complete
19304	Mastectomy, subcutaneous
19350	Nipple/areola reconstruction

Covered CPT CodesCPTCovered

00402	Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; reconstructive procedures on breast (eg, reduction or augmentation mammoplasty, muscle flaps).
00926	Anesthesia for procedures on male genitalia (including open urethral procedures); radical orchiectomy, inguinal.
11980	Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin).
14040	Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less.
15100-15101	Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less...
15771	Grafting of autologous fat by liposuction technique, 50 cc or less.
17380	Electrolysis epilation, each 30 minutes.
17999	Unlisted procedure, skin, mucous membrane and subcutaneous tissue.
19304	Mastectomy, subcutaneous.
19307	Mastectomy, modified radical...

1–10 of 25

1/3

HCPCS CodesHCPCSCovered

C1789	Prosthesis, breast (implantable).
C1813	Prosthesis, penile, inflatable.
L8600	Implantable breast prosthesis, silicone or equal.
S0189	Testosterone pellet, 75 mg.

Covered CPT CodesCPTCovered

19300

Mastectomy for gynecomastia

HCPCS CodesHCPCS

No codes listed

CPT codes appearing in this sectionCPT

0686T	Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant hepatocellular tissue, including image guidance
0888T	Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant renal tissue, including imaging guidance
55899	Unlisted procedure, male genital system [when specified as histotripsy of prostate tissue]

CPT Codes listedCPT

15756	Free muscle flap with or without skin with microvascular anastomosis
15757	Free skin flap with microvascular anastomosis
15758	Free fascial flap with mocrovascular anastomosis
15833	Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg
15836	Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm
15878	Suction assisted lipectomy; upper extremity
15879	Suction assisted lipectomy; lower extremity
35206	Repair blood vessel, direct; upper extremity
35226	Repair blood vessel, direct; lower extremity
35236	Repair blood vessel with vein graft; upper extremity

1–10 of 16

1/2

HCPCS codes present in this document segmentHCPCS

S2065	Simultaneous pancreas kidney transplantation
S2152	Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre- and post- transplant care in the global definition
S9339	Home therapy; peritoneal dialysis, administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately

BMI thresholds — Bariatric eligibility

Adult and adolescent BMI eligibilityBMI > 40; or BMI > 35 with at least one inadequately controlled obesity-related comorbidity (e.g., type 2 diabetes, hypertension, dyslipidemia, moderate-to-severe OSA, MASLD/MASH, cryptogenic cirrhosis, cardiovascular disease, pseudotumor cerebri, refractory GERD, severe osteoarthritis).

BMI adjustment for Asian descentBMI thresholds reduced by 2.5 kg/m2 for patients of Asian descent.

Prior Authorization, Documentation, and Denial Risks

Prior Authorization

Verify benefits and authorization rules with member's plan

Coverage and preauthorization requirements are determined by the member's benefit plan; CPT and other codes listed in this policy are informational only and do not guarantee coverage — providers must verify member benefits and follow the member's plan preauthorization/certification procedures.

Prior Authorization

Obtain prior authorization; follow CMS/state rules for Medicare/Medicaid

Obtain prior authorization or a coverage determination per the member's benefit; Medicare/Medicaid follow CMS or state determinations when applicable — when Medicare CMS determinations are absent, the commercial policy applies. Use the CPT/HCPCS codes listed in the policy only for informational billing guidance (e.g., CPT 19499 for unlisted breast procedures as noted).

Prior Authorization

Prior authorization must document BMI, accreditation, tobacco abstinence, multidisciplinary evaluation

Background and Evidence Summary

Athletic pubalgia, also called sports hernia or Gilmore's groin, is an uncommon and poorly defined cause of chronic groin pain in athletes. It is typically related to repetitive stress of the lower abdominal and upper thigh musculature and often develops insidiously rather than after a single traumatic event. Diagnosis is primarily clinical and can be difficult because there is no discernible frank hernia in most cases and there is no widely accepted, uniform definition or diagnostic standard for the condition.

Initial management is conservative and includes rest, NSAIDs, physical therapy, and image‑guided injections. When an adequate trial of these nonoperative measures fails, surgery is sometimes considered; however, published surgical series are limited, randomized controlled data are scarce, and there is no consensus on patient selection, operative technique, or standardized perioperative care.

Because of the limited and low‑quality evidence base and the lack of agreement on diagnostic criteria and treatment approach, SelectHealth’s Commercial Plan and CHIP policies state that athletic pubalgia (sport's hernia) repair is considered experimental/investigational and is not covered.

Key Definitions and Terms

Athletic pubalgia (sports hernia)

DefinitionAthletic pubalgia (sports hernia) — a poorly understood cause of chronic groin pain in athletes without a discernible hernia, often due to repetitive musculotendinous stress.

Clinical featuresTypically presents insidiously with overuse-type pain from lower abdominal and upper thigh musculature; diagnosis is clinical and can be elusive.

Initial managementInitial treatment is conservative (rest, ice, NSAIDs, physical therapy, guided injections); surgery considered only after failed conservative therapy.

Autologous Fat Transfer (AFT)

DefinitionAutologous Fat Transfer (AFT) — lipoinjection of autologous adipose tissue into the breast to reconstruct or augment contour, typically performed in 1–3 stages.

Volume range

Policy Summary

PayerSelectHealth

PolicyGeneral Surgery — Coverage Criteria (clinical/medical policy)

Policy CodePolicy N/A

Change TypeMaterial revisions to Commercial Plan criteria and added liposuction-for-lymphedema section

Effective DateN/A

Last ReviewJun 7, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document that the member meets all listed medical necessity criteria, including required assessments and conservative therapy trials.

SourceLink

On This Page

BMI threshold of interest

Super‑obese BMI consideration> 50 kg/m2 — procedure types such as biliopancreatic diversion with duodenal switch are frequently used and studied in this group.

Clinical notePatients with BMI >50 kg/m2 are often described as ‘super-obese’ and may be considered for more malabsorptive operations due to greater expected weight loss.

Evidence contextMany published studies of BPD/DS and distal procedures focus on patients with BMI ≥ 50 kg/m2.

Body Mass Index (BMI) — Gastric diversion

Primary BMI requirement for gastric diversion> 35 kg/m2 OR BMI < 35 if the member has had a prior sleeve gastrectomy (i.e., prior sleeve may qualify lower BMI).

Symptom requirementDaily reflux symptoms despite maximum PPI therapy required in addition to BMI criterion.

Objective testingObjective evidence of reflux (DeMeester >14.7 or EGD with grade C/D esophagitis or Barrett's) is required alongside BMI criterion.

Duration for gender dysphoria diagnosis

Minimum duration for diagnosis>= 6 months — gender dysphoria must persist at least six months for DSM-5-TR diagnosis in adolescents and adults.

Manifestation criteriaDuration requirement accompanies at least two DSM-5-TR criteria (e.g., marked incongruence with primary/secondary sex characteristics, desire to be other gender).

Policy interpretationWPATH SOC-8 'marked and sustained' guidance is interpreted through the DSM-5‑TR six-month minimum duration.

Hormone therapy prior to some surgeries

Pre‑operative hormone therapy duration6 months continuous hormone therapy prior to gonadectomy or genital reconstructive surgery unless a medical contraindication or if not desired.

ApplicabilityRequirement applies to gonadectomy and many genital procedures as listed in policy (hysterectomy/oophorectomy, orchiectomy, vaginoplasty, phalloplasty, etc.).

Exception allowanceMedical contraindication or patient choice may exempt the 6-month requirement when documented.

Duration for diagnosis — Gender dysphoria

Minimum duration statedAt least 6 months — DSM‑5‑TR requirement for gender dysphoria diagnosis used to support coverage decisions for surgical care.

Required manifestationsDiagnosis must be associated with clinically significant distress or impairment and meet DSM criteria manifesting two or more specified features.

Policy useDuration supports interpretation of WPATH SOC‑8 'marked and sustained' requirement for surgical recommendations.

Conservative therapy duration, BMI, limb volume difference

Conservative therapy duration for delayed ILRConservative lymphedema therapy for a minimum of ≥ 1 month (engagement and maintained compliance) is required prior to delayed lymphovenous bypass.

BMI limit for lymphovenous bypassBMI ≤ 35 required for eligibility for lymphovenous bypass (delayed ILR).

Limb volume threshold for liposuctionLimb volume difference > 25% required for consideration of liposuction for lymphedema.

Prior Authorization

Authorize only covered CPTs; exclude investigational CPTs

Do not authorize CPTs listed as 'Not covered/Investigational' for the indicated bariatric or other investigational procedures; prior authorization is implied for covered bariatric CPTs when clinical criteria are met and should not be granted for codes the policy lists as investigational.

Documentation Required

Include preoperative nutritional assessment within 1 year

For Commercial Plan bariatric criteria, include documentation of a preoperative nutritional assessment performed within one year of surgery that documents weight history and assesses maladaptive eating disorders (note: the prior requirement to evaluate micronutrient deficiencies was removed).

Prior Authorization

Document all GAMST medical necessity criteria for prior authorization

Prior authorization requests for gender-affirming procedures must include documentation that all medical necessity criteria are met (e.g., member age ≥ 18, qualified HCP assessment per WPATH SOC‑8, diagnosis of marked and sustained gender dysphoria, and other listed interdisciplinary and consent requirements).

Prior Authorization

Submit prior auth showing ILR eligibility, operative plan and postoperative tolerance

Prior authorization for lymphatic reconstruction must include documentation that eligibility criteria are met: for immediate ILR, an operative plan for lymph node dissection or cross‑over sentinel node and attestation of ability to tolerate post‑surgical compression/therapy; for delayed reconstruction, diagnostic criteria, quantitative imaging, BMI ≤ 35, and prior certified conservative therapy.

Prior Authorization

Prior authorization required for lipedema liposuction; must document setting and criteria

Prior authorization is required for liposuction/excision/debulking for lipedema and the procedure must be performed in a hospital or ambulatory surgical center; requests must document diagnostic features and failed conservative therapy.

Step Therapy

Document trial of conservative therapy before surgery

Before considering surgery for athletic pubalgia, document a trial of conservative therapy (rest, NSAIDs, physical therapy, fluoroscopically‑guided injections) and that reasonable non‑surgical options were discussed and attempted.

Conservative measures (rest, NSAIDs, PT, injections) should be attempted first
Document discussion and failed trial of non-surgical options

Step Therapy

Discontinue gynecomastia‑inducing medications for ≥1 year before surgery or document waiver

When gynecomastia‑inducing medications are identified, they must be discontinued for at least one year, when medically appropriate, prior to considering surgery — document medication discontinuation or an authorized waiver from the prescribing physician.

Step Therapy

Document prior conservative lymphedema therapies and failure

For lymphedema‑related surgeries, document engagement and maintained compliance with conservative lymphedema treatments (compression therapy plus additional modalities) and, for liposuction coverage, document failure of both compression and lymphedema pump therapy.

Compliance with certified lymphedema therapist care for ≥1 month (delayed reconstruction)
Failed conservative therapy including compression and lymphedema pump for liposuction

Documentation Required

Include required referral letter contents and clinical rationale

Prior authorization requests and referral letters must include required elements: patient identifiers, assessment results/diagnoses, clinician licensure/experience, statement that WPATH criteria (when applicable) have been met, clinical rationale, and confirmation of informed consent.

Documentation Required

Provide documentation that supports all eligibility criteria and quantitative testing

Medical records submitted for coverage must support eligibility criteria (e.g., BMI and comorbidity evidence for bariatric surgery; ISL staging, limb volume difference >25% and prior failed conservative therapy for lymphedema liposuction) and include relevant quantitative testing and procedure‑specific documentation.

Denial Risk

Missing required documentation or using investigational CPTs may cause denial

Failure to document required thresholds, facility accreditation/proctoring status, 1‑month tobacco abstinence, preoperative nutritional assessment within one year (where required), or other listed criteria may trigger denial; services billed with CPTs listed as investigational for the indicated use may be denied.

Morbid obesity — Definition

Morbid obesity definitionBMI > 40 kg/m2 — defined as morbid obesity with associated increased morbidity and mortality.

Clinical impactMorbid obesity is associated with hypertension, diabetes, coronary disease, stroke, osteoarthritis, respiratory problems, and some cancers.

Surgical contextSurgical options (sleeve gastrectomy, gastric bypass, BPD/DS) are considered for patients who fail non-surgical weight loss attempts.

Short-limb Roux-en-Y gastric bypass — Definition

Short‑limb Roux‑en‑Y gastric bypass (RYGB) definitionRoux‑en‑Y gastric bypass with a Roux limb less than 150 cm measured from the gastrojejunostomy — considered the standard gastric bypass technique.

Clinical roleShort‑limb RYGB is a commonly covered bariatric procedure for morbid obesity and GERD alleviation when criteria are met.

Distinction noteLong‑limb (distal) RYGB is defined by a longer Roux limb (>150 cm) and is considered separately due to different malabsorptive effects.

Long-limb Roux-en-Y gastric bypass — Definition

Long‑limb Roux‑en‑Y gastric bypass definitionA gastric bypass with an extended Roux limb (>150 cm measured from the ileocecal valve) intended to increase malabsorption and weight loss, at the cost of greater nutritional disturbances.

Physiologic effectLonger Roux limb reduces absorptive length, increasing weight loss but raising risk of electrolyte and micronutrient disturbances.

Surgical measurementTrue long‑limb GBP requires measurement backward from the ileocecal valve to ensure adequate limb length.

Biliopancreatic diversion with duodenal switch (BPD/DS)

Biliopancreatic diversion with duodenal switch (BPD/DS)A malabsorptive procedure combining partial sleeve gastrectomy with preservation of the pylorus and creation of a Roux limb with a short common channel; associated with greater weight loss but increased long‑term risk of micronutrient deficiencies.

Indication noteOften advocated for very severe obesity (commonly BMI > 50 kg/m2) where greater excess weight loss is desired.

AvailabilityPerformed at select centers; considered more complex with higher long‑term nutritional risk than standard RYGB.

Laparoscopic sleeve gastrectomy (LSG)

Laparoscopic sleeve gastrectomy (LSG)A restrictive procedure removing a portion of the stomach to create a sleeve; short‑term studies show promising weight loss and metabolic improvements though long‑term data are limited.

Evidence cautionSystematic reviews and technology assessments note limited long‑term safety and efficacy data beyond 1–6 years in many studies.

Clinical useLSG is commonly offered as a primary bariatric operation and as part of staged or conversion strategies.

12-month nonprogression — Outcome metric

12‑month nonprogression outcomeNonprogression rate at 12 months after cryoablation reported at approximately 85–86% in prospective and pooled analyses.

Clinical significanceDemonstrates high rates of disease control and functional improvement for suitable desmoid tumors after cryoablation.

Evidence basisDerived from prospective trials and meta‑analyses summarized in the policy evidence review.

Suitable tumor — Cryoablation

Suitable tumor for cryoablationExtra‑abdominal desmoid tumors that are small‑to‑moderate in size, symptomatic, progressive after medical therapy, and not adjacent to critical structures where complete ablation would risk nerves or vital tissues.

Treatment contextUsually reserved for progressive or symptomatic tumors after failure of at least two lines of medical therapy.

Efficacy caveatEfficacy is reduced for larger tumors or those adjacent to critical structures where complete ablation is not feasible.

Roux-en-Y gastric bypass (RYGB)

Roux‑en‑Y gastric bypass (RYGB) definitionA gastric diversion procedure creating a small gastric pouch drained by a Roux limb from the proximal jejunum used to alleviate GERD symptoms and for bariatric indications.

Procedure variantsShort‑limb RYGB (Roux limb ≤150 cm) is the standard approach; RYGB may be used to treat medically refractory GERD in appropriate patients.

CodingPolicy lists CPT codes (e.g., 43644, 43645) associated with RYGB procedures when criteria are met.

DeMeester score — Definition

DeMeester score definitionComposite score measuring esophageal acid exposure from a 24–48 hour ambulatory pH probe; a value >14.7 is considered abnormal reflux per this policy.

Clinical useUsed as objective evidence of pathologic reflux when evaluating candidates for gastric diversion for refractory GERD.

Reference/calculationPolicy references DeMeester score calculation and an online DMS calculator for interpretation.

Gender dysphoria — Definition

Gender dysphoria definitionMarked incongruence between one's experienced/expressed gender and assigned gender causing significant distress or impairment; in adolescents and adults it must persist for at least six months and meet DSM‑5‑TR criteria.

Manifestation requirementsDiagnosis requires at least two DSM‑5‑TR features (e.g., desire to be other gender, desire to be rid of primary/secondary sex characteristics) and associated functional impairment.

Use in policyThis DSM‑5‑TR definition is used to operationalize WPATH SOC‑8 ‘marked and sustained’ requirement for surgical recommendations.

Gender dysphoria — Definition with duration

DSM‑5‑TR duration elementGender dysphoria diagnosis requires at least six months duration in adolescents and adults per DSM‑5‑TR; WPATH SOC‑8 ‘marked and sustained’ is interpreted via this six‑month minimum.

Clinical criteriaDiagnosis is manifested by two or more specified criteria and associated distress/impairment.

Guideline linkagePolicy cites WPATH SOC‑8 and aligns its surgical recommendation requirements with DSM‑5‑TR duration criteria.

WPATH SOC-8 — Standards reference

WPATH SOC‑8 referenceStandards of Care version 8 (WPATH SOC‑8) — referenced as the guideline for provider requirements and recommendations for gender‑affirming interventions.

Guideline purposeSOC‑8 offers multidisciplinary, patient‑centered standards to guide informed decision‑making and harm reduction in gender‑affirming care.

Policy useSelectHealth references SOC‑8 to define minimum professional assessments and multidisciplinary documentation expected for surgical coverage decisions.

Gender dysphoria — Alternate reference

Gender dysphoria alternate framingWPATH frames gender incongruence as discomfort/distress from discrepancy between gender identity and assigned sex; DSM‑5‑TR provides diagnostic criteria used in policy.

Policy alignmentPolicy aligns WPATH and DSM‑5‑TR definitions to require clinical documentation of marked, sustained gender incongruence (minimum six months) for surgical consideration.

Multidisciplinary carePolicy emphasizes multidisciplinary documentation consistent with SOC‑8 for treatment planning and surgical recommendations.

Gender-affirming interventions — Definition

Gender‑affirming interventions definitionInterventions include puberty suppression, hormone therapy, and gender‑affirming surgeries intended to affirm a person's gender identity as part of multidisciplinary care.

ScopeInterventions span medical, surgical, and supportive services and are individualized per patient goals and SOC‑8 guidance.

Policy implicationCoverage decisions reference clinical indication, documentation, and alignment with SOC‑8 to determine medical necessity.

Gender dysphoria — DSM-5-TR duration

DSM‑5‑TR duration requirement (policy citation)Policy cites DSM‑5‑TR: gender dysphoria present for at least six months as a diagnostic requirement and as operationalization of WPATH ‘marked and sustained’.

Clinical documentationDocumentation should show duration and meet DSM criteria to support medical necessity for surgical interventions.

Guideline concordanceSelectHealth interprets WPATH SOC‑8 through DSM‑5‑TR duration criteria for coverage decisions.

Gynecomastia — Definition

Gynecomastia definitionExcessive development of the male mammary glands due mainly to ductal proliferation with periductal edema; may be physiologic in adolescence or secondary to hormonal causes.

Clinical gradingGynecomastia graded I–IV (Grade I small, Grade II moderate exceeding areola, Grade III with skin redundancy, Grade IV marked enlargement with feminization).

Surgical contextSurgery is considered when persistent, symptomatic, and meeting documented criteria per policy (e.g., Grade II+; other medical requirements).

Gynecomastia Grades I-IV

Gynecomastia grading overviewGrades I–IV: I = small localized tissue; II = moderate enlargement exceeding areola; III = moderate enlargement with distinct edges and skin redundancy; IV = marked enlargement with feminization and skin redundancy.

Coverage relevancePolicy requires Grade II or greater for many coverage pathways and documents use of ASPS‑adapted grading.

Clinical noteCertain exclusions apply (e.g., liposuction alone considered unproven); medication‑induced cases require discontinuation when medically appropriate before surgery.

ISL staging — Overview

ISL staging system overviewInternational Society of Lymphology (ISL) stages: Stage 0 subclinical, Stage I early reversible swelling, Stage II moderate persistent swelling with fibrosis, Stage III late with significant skin/tissue changes.

Clinical implicationsStage informs eligibility for procedures such as liposuction (Stage 2–3 unilateral non‑pitting required) and ILR considerations.

Documentation requirementPolicy requires ISL staging documented in the medical record to support eligibility for lymphatic procedures.

Stemmer's sign negative — Definition

Stemmer's sign negative definitionStemmer's sign negative: a fold of skin can be pinched and lifted at the base of the second toe or base of the middle finger — used to distinguish lipedema from lymphedema.

Diagnostic utilityStemmer's sign negativity is part of the clinical criteria for lipedema and helps exclude lymphedema unless comorbid.

Policy applicationDocumentation of Stemmer's sign negative is required for lipedema coverage criteria per policy.