OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

ModifiedSelectHealthPolicy N/A

Varicose Vein Procedures (General Surgery) — Coverage Criteria

Customize your policy alerts

Sign up for all SelectHealth policy alerts

Know when SelectHealth releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This document governs SelectHealth's coverage determinations for varicose vein procedures (Policy #193) as part of the General Surgery medical policies; it affects providers treating SelectHealth Commercial, Medicare, and Community Care (Medicaid) members. (Note: this output is based on the first part of the policy document provided.)

Policy Summary

PayerSelectHealth

PolicyVaricose Vein Procedures (General Surgery) — Coverage Criteria

Policy CodePolicy N/A

Change TypeMultiple material edits (criteria additions, clarifications, and revisions)

Effective DateN/A

Last ReviewJun 7, 2025

Next Review DateN/A

Key ActionVerify member benefits and obtain any required prior authorization before submitting requests for procedures.

SourceLink

POLICY UPDATE CHANGES

For Commercial Plan Policy, added criterion that AFT is indicated in breast augmentation for patients treated for contralateral breast cancer seeking a symmetry procedure.

For Commercial Plan Policy, clarified requirements in criterion #8a regarding preoperative psychological clearance for members with specified severe psychiatric conditions.

Modified requirements in criteria #7 regarding preoperative nutritional assessment content (weight history; assesses eating habits; removal of micronutrient deficiency evaluation).

Added new Section B - Criteria for Adolescents for coverage determinations of bariatric procedures for adolescents.

Allowed bariatric surgery at facilities undergoing recruitment or pre-credentialing for MBSAQIP accreditation.

Policy affirms single lifetime coverage of bariatric surgery with specific exceptions (initial BMI > 60 allowing biliopancreatic bypass after sleeve, or prior laparoscopic gastric banding).

02/23/26Last reviewed (Varicose Vein policy)

MultipleTable of contents policies

Part 1 of 15This brief portion

BMI > 40Adult BMI threshold

1 per lifetimeDefault bariatric limit

~15Related policies listed

Coverage Criteria and Clinical Requirements

inv-01: Not covered — Athletic Pubalgia (Sport's Hernia) Repair

Select Health does NOT cover athletic pubalgia (sport's hernia) repair for Commercial plan and CHIP.

Athletic pubalgia (sport's hernia) repair: Select Health does NOT cover athletic pubalgia (sport's hernia) repair due to the ill-defined nature of the condition and lack of consensus on diagnosis and treatment; this is considered experimental/investigational under the plan.

Applies to Commercial plan and CHIP.

inv-02: Covered Indications — Autologous fat transfer in conjunction with covered breast reconstructions for listed indications

Covered when performed in conjunction with medically necessary breast reconstruction for the listed indications.

Covered Indications: 1) Surgical correction following a medically necessary mastectomy or lumpectomy resulting in significant deformity; 2) Repair of significant/obvious breast asymmetry directly related to trauma where deformity/asymmetry is apparent after the injury; 3) Breast augmentation as a symmetry procedure for patients treated for contralateral breast cancer (AFT permits smaller volume augmentation with broader distribution than implants).

Autologous fat transfer for other breast indications is considered cosmetic and not covered.

inv-03: Adolescent MBS coverage — ALL criteria for adolescents (ages 13-18)

Covered when ALL of the following are met for adolescent patients (ages 13–18):

Adolescent eligibility: 1) Age 13–18; AND 2) BMI > 40 OR BMI > 35 with at least one inadequately controlled obesity‑related disease (examples include type 2 diabetes, hypertension, dyslipidemia, moderate-to-severe OSA, MASLD/MASH, cryptogenic cirrhosis, cardiovascular disease, pseudotumor cerebri, refractory GERD, severe osteoarthritis); AND 3) Surgery performed at an MBSAQIP‑accredited facility or a facility actively pursuing MBSAQIP accreditation under supervision/proctoring as specified; AND 4) One month tobacco abstinence prior to surgery; AND 5) Evidence all reasonable non‑surgical alternatives were discussed and attempted; AND 6) Multidisciplinary evaluation within six months of surgery including nutritional assessment (weight history, dietary habits, counseling) and psychological assessment when indicated (behavioral assessment by a qualified licensed pediatric/adolescent behavioral health provider documenting mature decision‑making, ability to provide surgical assent, and adequate family/social support).see node text

Presence of mild-to-moderate depression is not a contraindication; facilities undergoing recruitment/pre-credentialing allowed per revision.

inv-04: Adult MBS coverage (Commercial) — ALL criteria for adults

Covered when ALL of the following are met for adults:

Adult eligibility: 1) Age ≥ 18; AND 2) BMI > 40 OR BMI > 35 with at least one inadequately controlled obesity‑related disease (examples include type 2 diabetes, hypertension, dyslipidemia, moderate-to-severe OSA, MASLD/MASH, cryptogenic cirrhosis, cardiovascular disease, pseudotumor cerebri, refractory GERD, severe osteoarthritis); AND 3) Surgery performed at an MBSAQIP‑accredited facility or a facility actively pursuing MBSAQIP accreditation under supervision/proctoring as specified; AND 4) One month tobacco abstinence prior to surgery; AND 5) Evidence all reasonable non‑surgical alternatives were discussed and attempted; AND 6) Multidisciplinary evaluation within six months of surgery including nutritional assessment (weight history, dietary habits, counseling) and psychological assessment when indicated;see node text

For patients of Asian descent, BMI thresholds are reduced by 2.5 kg/m2.

inv-05: Covered procedures — list of procedures covered by policy

Select Health covers the following bariatric procedures when clinical criteria are met:

Covered procedures list: Laparoscopic/open Roux‑en‑Y gastric bypass with short limb (≤150 cm); laparoscopic/open sleeve gastrectomy (longitudinal gastrectomy); biliopancreatic diversion with duodenal switch; loop duodenal switch (SADS/SIPS); one‑anastomosis gastric bypass/mini gastric bypass (as listed); and specified revisional procedures when criteria are satisfied.

Covered CPT codes include 43645, 43774, 43775, 43845, 43846, 43848, 43860, 43865.

inv-06: Not covered procedures — procedures not covered by policy

Select Health does NOT cover the following bariatric procedures or techniques:

Not covered list: Endoscopic sleeve gastroplasty; laparoscopic gastric banding (adjustable gastric restrictive devices) and associated placement/revision/removal components; Garren gastric bubble; gastric bypass with long‑limb (>150 cm) (distal gastric bypass); gastric wrapping; gastroplasty (stomach stapling); intragastric balloons; jejunoileal bypass; loop gastric bypass; vagal nerve blocking/stimulation; and other procedures explicitly listed as investigational/unproven.

Codes such as 43770–43773, 43842–43843, 43847, 43886–43889, 43889, 43659, 43999 are listed as investigational/unproven.

inv-07: Revision and lifetime limits — coverage limitations and revision rules

Coverage limitations and revision rules:

Revisions and lifetime rules: 1) Bariatric surgery is covered once per lifetime, except in specified situations: individuals with initial BMI > 60 may have biliopancreatic bypass with duodenal switch after a prior sleeve gastrectomy, and individuals with prior laparoscopic gastric banding may have additional procedures; these are not considered revisions of the initial procedure. 2) Revisional bariatric surgery is covered only for complications of prior bariatric surgery. 3) Conversion of sleeve gastrectomy to Roux‑en‑Y gastric bypass is covered for medically refractory GERD and/or dysphagia attributable to the sleeve after failure of maximal medical therapy.

Revision and credentialing clarifications appear in revision history entries.

inv-08: Covered Procedures with Criteria — covered when ALL applicable clinical criteria are met (refer to policy clinical criteria)

Covered when ALL applicable policy clinical criteria are met:

Procedure coverage: Procedures listed in the 'Covered' CPT code group (e.g., 43645, 43775, 43845, 43846, etc.) are covered when the policy's clinical eligibility criteria (BMI thresholds, failed conservative therapy, required evaluations and testing) are satisfied.

Clinical criteria such as BMI thresholds and objective testing are referenced elsewhere in the policy (e.g., gastric diversion criteria).

inv-09: Not Medically Necessary / Investigational — CPT codes considered investigational/unproven and not covered

The following CPT codes are considered investigational/unproven for these indications and are not covered:

Investigational procedures codes: Claims billed with CPT codes listed in the 'Not covered' investigational group (for example 43659, 43770–43773, 43842–43843, 43847, 43886–43889, 43889, 43999) will be denied as investigational/unproven for the bariatric indications addressed by this policy.

List is illustrative of codes shown in policy; refer to coding tables for full lists.

inv-10: Covered when ALL of the following are met — general statement about required preoperative assessments, credentialing and lifetime limits

Covered when ALL of the following are met (general conditions applicable to bariatric procedures):

Preoperative assessments and facility requirements: 1) Documentation of required preoperative assessments including a nutritional assessment within one year prior to surgery (weight history and assessment of eating habits) and psychological clearance when indicated; AND 2) Procedure performed at an MBSAQIP‑accredited facility or an approved supervised facility undergoing MBSAQIP recruitment/pre‑credentialing per policy; AND 3) One month tobacco abstinence prior to surgery; AND 4) Evidence that all reasonable non‑surgical alternatives were discussed and attempted; AND 5) Adherence to lifetime limits unless a specified exception applies.

Preoperative psychological clearance criteria clarified for members with severe psychiatric conditions; adolescent-specific requirements described in Section B.

inv-11: Section B - Criteria for Adolescents — adolescent-specific bariatric criteria

Adolescent-specific behavioral health and assent requirements (Section B):

Adolescent behavioral assessment: Behavioral assessment must be performed by a psychologist, psychiatrist, or other licensed behavioral healthcare provider with pediatric/adolescent training; documentation must include evidence of mature decision‑making, awareness of risks and benefits, the adolescent's ability to provide surgical assent, and adequate family/social support.

These elements are required to consider an adolescent for metabolic and bariatric procedures.

inv-12: Medical necessity and candidacy — covered when clinical and prior-therapy conditions are met

Covered when clinical and prior‑therapy conditions are met (examples given in policy):

Cryoablation candidacy: Cryoablation for extra‑abdominal desmoid tumors is considered medically necessary for patients with progressive disease after failure of at least two lines of medical therapy; candidacy favors small to moderately sized tumors where complete ablation is feasible and where tumor location relative to critical structures permits safe treatment.failure of >= 2 lines of medical therapy

Evidence shows high 12‑month nonprogression rates and favorable safety profile; larger tumors or tumors adjacent to critical structures have reduced efficacy.

inv-13: Coverage criteria for gastric diversion — covered when ALL of the following are met

Covered when ALL of the following are met for gastric diversion addressing GERD in selected patients:

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

Follow plan-specific benefit determination.

inv-14: GAMST - General surgical eligibility — gender-affirming surgical eligibility criteria

Select Health considers gender-affirming surgical procedures medically necessary when ALL of the following general criteria are met:

GAMST General Criteria: 1) Member is age ≥ 18; AND 2) HCPs assessing transgender and gender diverse individuals meet minimum requirements per WPATH SOC8; AND 3) HCPs consult with other disciplines as appropriate; AND 4) Gender dysphoria is diagnosed and is marked and sustained per DSM‑5‑TR (minimum 6 months); AND 5) Other explanations for gender incongruence have been excluded; AND 6) Impacts of surgical treatments on other mental health and physical conditions have been discussed; AND 7) The member has capacity to consent to the requested treatment; AND 8) Social transitioning has occurred and risks/benefits have been discussed.>= 6 months for gender dysphoria

Applies to all gender-affirming surgical interventions.

inv-15: GAMST - Breast removal — requirements for breast removal as GAMST

Requirements specific to breast removal (mastectomy) as part of gender-affirming care:

Breast removal (GAMST): 1) Member is age ≥ 18; AND 2) Single referral letter from a qualified healthcare professional (per Appendix B); AND 3) Surgeon has assessed breast cancer risk factors.

Referral letter must follow policy appendix format and include required assessment elements.

inv-16: General medical necessity criteria for gender-affirming surgery — ALL requirements

General medical necessity criteria for gender-affirming surgery (summary):

General medical necessity for GAMST: 1) Age ≥ 18; AND 2) Qualified HCP assessments per WPATH SOC8; AND 3) Multidisciplinary consultation as appropriate; AND 4) Diagnosis of marked and sustained gender dysphoria per DSM‑5‑TR; AND 5) Exclusion of other explanations; AND 6) Discussion of impacts on mental and physical health; AND 7) Capacity to consent; AND 8) Social transition considered/practiced.

These general criteria underpin coverage for specific GAMST procedures.

inv-17: Breast augmentation (implants/lipofilling) — requirements and notes

Requirements specific to breast augmentation (implants or lipofilling) in GAMST:

Breast augmentation (GAMST): 1) Member is age ≥ 18; AND 2) Single referral letter from a qualified healthcare professional; AND 3) Surgeon has assessed breast cancer risk factors. Note: More than one breast augmentation (excluding fat grafting) is considered cosmetic and not medically necessary; replacement of implants for medical reasons is not subject to that cosmetic exclusion.

Current guidelines do not mandate a specific hormone duration for adults prior to augmentation, though hormone treatment may be advised for optimal results.

inv-18: Gonadectomy and genital reconstructive surgery — requirements for these procedures

Requirements for gonadectomy and genital reconstructive surgeries:

Gonadectomy and genital reconstructive surgery: 1) Member is age ≥ 18; 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 and fertility preservation options have been discussed and pursued if desired.6 months hormone therapy

Applies to hysterectomy/oophorectomy, orchiectomy, metoidioplasty, phalloplasty, vaginoplasty, and other genital procedures listed.

inv-19: Colorado Commercial Plan Coverage Criteria — Colorado-specific GAMST criteria

Colorado commercial plan — Covered when ALL of the following are met:

Colorado commercial GAMST criteria: 1) Member is at least 18 years of age; AND 2) Diagnosis of Gender Dysphoria per DSM‑5‑TR/WPATH criteria with at least 6 months duration and clinically significant distress or impairment; AND 3) Requested procedure is among those covered under the Colorado commercial plan filing or meets the criteria in policy #386;>= 6 months

Colorado filing lists specific covered procedures (e.g., hormone therapy, genital and non‑genital surgeries, facial procedures, breast/chest procedures, lipofilling, etc.).

inv-20: Gynecomastia surgery: covered when criteria met — EITHER/ALL logic for coverage

Select Health covers surgery for gynecomastia when EITHER item 1 or 2 is met; when item 2 is selected, ALL subcriteria a–g must be met.

Gynecomastia primary pathways: Either: 1) Klinefelter's syndrome; OR 2) Persistent gynecomastia (pubertal onset persisted ≥2 years OR post‑pubertal onset persisted ≥1 year) with ALL of the following subcriteria a–g met: a) glandular breast tissue documented on physical exam and/or mammography; b) ASPS Grade II or greater; c) persistent breast pain despite analgesics; d) discontinuation of potential gynecomastia‑inducing drugs/substances for ≥1 year when medically appropriate (waiver allowed with prescriber statement); e) persistence despite correction of underlying causes; f) hormonal causes excluded by appropriate labs and, if present, treated ≥12 months before surgery; g) patient BMI < 30.adolescent ≥2 years; post‑pubertal ≥1 year; BMI < 30

Suction lipectomy alone is considered unproven and not covered; surgery performed primarily for cosmetic reasons or solely for psychological complaints is not covered.

inv-21: Medical necessity criteria for gynecomastia surgery — covered when ONE of the following is met

Covered when ONE of the following is met (detailed requirements for non‑Klinefelter's pathway):

Primary allowable indications: 1) Klinefelter's syndrome; OR 2) Pubertal (adolescent) onset gynecomastia persistent ≥2 years OR post‑pubertal onset persistent ≥1 year with all additional conditions met (a–g): glandular tissue confirmation, Grade II+, persistent pain despite analgesics, discontinuation of causative drugs ≥1 year when appropriate, persistence despite correction of underlying causes, hormonal causes excluded/treated ≥12 months if present, and BMI < 30.adolescent ≥2 years; post‑pubertal ≥1 year; BMI < 30

Requirements a–g are conjunctive when selecting pathway 2.

inv-22: Immediate Lymphatic Reconstruction — Breast Cancer — covered when ALL of the following are met (A AND B)

Immediate lymphatic reconstruction for breast cancer is covered when ALL of the following A and B are met:

Immediate ILR — Breast Cancer: A. Surgical plan includes axillary lymph node dissection at time of initial cancer resection meeting at least one of: axillary lymph node dissection; cross‑over sentinel node draining the arm; planned radiation therapy; or planned mastectomy. AND B. Attestation that the individual can tolerate post‑surgical compression therapy and physical therapy per the treating lymphedema provider.

Applies to prophylactic lymphovenous bypass performed at time of nodal dissection.

inv-23: Immediate Lymphatic Reconstruction — Other Cancers — covered when ALL of the following are met (A AND B)

Immediate lymphatic reconstruction for other cancers is covered when ALL of the following A and B are met:

Immediate ILR — Other Cancers: A. Surgical plan includes lymph node dissection at the time of initial cancer resection meeting at least one of: lymph node dissection or a cross‑over sentinel node that would drain an arm or leg. AND B. Attestation that the individual can tolerate post‑surgical compression therapy and physical therapy per the treating lymphedema provider.

Coverage applies when both A and B are satisfied.

inv-24: Delayed Lymphatic Reconstruction — covered when ALL of the following A-D are met

Delayed lymphatic reconstruction (lymphovenous bypass) is covered when ALL of the following A–D are met:

Delayed lymphovenous bypass eligibility: A. Diagnostic criteria: at least one sign (pitting or non‑pitting edema, fibrosis, limited mobility from swelling) AND at least one symptom (heaviness, achiness, pain, tightness, numbness/tingling, clothing not fitting, fatigue) consistent with lymphedema, and diagnosis of ≥ ISL Stage I; AND B. At least one positive objective imaging/measurement for unilateral disease (lymphoscintigraphy with ≥1‑hour delayed transit or dermal backflow OR ICG imaging with obstructed linear channels with reticular/stardust pattern OR MRI lymphangiography showing obstruction/dermal backflow); AND C. Eligibility: BMI ≤ 35; compliance with ≥1 month of certified lymphedema therapist‑supervised conservative therapy including compression plus manual drainage/pump/targeted exercises; and demonstrated ability to tolerate post‑surgical compression therapy and PT; AND D. No contraindications present (see contraindications list: transient lymphedema, untreated lipedema without lymphatic dysfunction, uncontrolled comorbidities, pregnancy, active infection, etc.).BMI ≤ 35; ≥1 month CLT supervised conservative therapy

Objective testing and documentation are required to establish eligibility.

inv-25: Liposuction for Lymphedema — covered when ALL of the following are met

Liposuction for lymphedema is covered when ALL of the following are met:

Liposuction coverage criteria: 1) Unilateral non‑pitting ISL Stage 2 or 3 lymphedema; AND 2) Limb volume difference > 25%; AND 3) Documented physical functional impairment; AND 4) Prior failure of conservative therapy including compression and lymphedema pump therapy.Limb volume difference >25%; ISL Stage 2 or 3

Procedure is covered when all elements are documented and conservative therapy has failed.

inv-26: General coverage statement — covered when ALL of the following are met

General coverage statement:

General coverage condition: Procedures listed in this policy are covered for the indications outlined above when the specific clinical criteria for those indications are fully met and required documentation is provided.

Billing/coding listings are informational; benefits and eligibility are determined by the member's individual plan at time of service.

inv-28: Extremity lipedema surgical coverage — covered when ALL of the following are met

Extremity lipedema surgical coverage — covered when ALL of the following are met:

Extremity lipedema criteria: 1) Procedure performed in a hospital or ambulatory surgical center; AND 2) Diagnosis documented by clinical exam and photography demonstrating bilateral symmetric thickened subcutaneous fat with pain/hypersensitivity and history of easy bruising, Stemmer's sign negative, and absence of pitting edema unless comorbid lymphedema; AND 3) Documented significant physical functional impairment or medical complications (e.g., recurrent cellulitis, skin ulceration); AND 4) Failed conservative management for six or more consecutive months (compression garments, non‑calibrated segmental lymphedema pump, or manual therapy); AND 5) Lack of improvement with weight loss and lack of improvement of swelling with limb elevation.>=6 months conservative therapy

Procedures must be performed in appropriate surgical setting; documentation and photography required.

inv-29: Trunk lipedema surgical coverage — covered when ALL of the following are met

Trunk lipedema surgical coverage — covered when ALL of the following are met:

Trunk lipedema criteria: 1) Procedure performed in a hospital or ambulatory surgical center; AND 2) Diagnosis documented by clinical exam and photography demonstrating pain/hypersensitivity, easy bruising, and tenderness/nodularity of fat deposits (dimpled or 'orange peel' texture); AND 3) Failed response to six or more consecutive months of conservative management (compression or manual therapy); AND 4) Lack of improvement with weight loss in the affected trunk areas.>=6 months conservative therapy

Documentation of diagnostic features and failed conservative therapy required.

inv-30: Excess skin removal — covered when ALL of the following are met

Excess skin removal following lipedema surgery — covered when ALL of the following are met:

Excess skin removal criteria: Excess skin removal is covered when it addresses functional problems following liposuction for lipedema of the trunk, legs, thighs, or hips or is required to provide pneumatic or magnetic compressive therapy post‑liposuction, and when clinical documentation supports the functional indication.

CPT codes such as 15832–15834, 15878–15879 may apply when criteria are met and documented.

Select Health considers athletic pubalgia (sport's hernia) repair to be not covered under Commercial plan policy and CHIP. The procedure is classified as experimental/investigational because the condition is ill‑defined and there is no consensus on appropriate surgical approaches.

Autologous fat transfer (AFT) is covered only when performed in conjunction with medically necessary breast reconstruction for the specific indications listed in the policy. AFT performed for any other breast indication (including solely cosmetic augmentations or contouring) is considered cosmetic and not covered. The policy lists CPT 19499 as the unlisted breast code used in documentation.

Members being considered for metabolic and bariatric surgery must not have other severe comorbidities that would materially increase perioperative morbidity or mortality; presence of such uncontrolled conditions would render the member ineligible for coverage.

Obsolete or abandoned bariatric procedures (for example, jejunoileal bypass, gastric wrapping with Teflon mesh, and the Garren gastric bubble) are not covered. These techniques are considered antiquated due to high complication rates and are excluded from coverage.

Bariatric surgery coverage is limited to one lifetime procedure. Exceptions to this one‑time limit are explicitly listed and include individuals with an initial BMI > 60 (allowing biliopancreatic bypass with duodenal switch after a prior sleeve gastrectomy) and individuals with a history of prior laparoscopic gastric banding; these additional procedures are not considered revisions.

Cryoablation is recognized as an effective local treatment option for extra‑abdominal desmoid tumors, particularly for patients with progressive disease after failure of at least two lines of medical therapy. It is less effective for larger tumors or lesions adjacent to critical structures where complete ablation may not be feasible or safe.

Medicare and Medicaid coverage may be governed by Centers for Medicare & Medicaid Services (CMS) national or local coverage determinations or by state Medicaid policy. When CMS has an adopted determination, that policy applies; when CMS or state determinations are absent, Select Health's commercial policy may be applied for Medicare or Community Care members.

This policy document is informational and is not a substitute for individualized clinical judgment. Coverage and reimbursement decisions are based on the member's specific benefit plan in effect at the time of service; providers and members should verify benefits and obtain applicable authorizations prior to treatment.

The policy lists numerous procedures that are considered cosmetic and not medically necessary when performed as components of gender‑affirming care (examples include abdominoplasty, blepharoplasty, body contouring, and many facial feminizing/masculinizing procedures). Specific mastectomy and nipple reconstruction codes (19303, 19304, 19350) are identified as not covered for those listed indications.

For gender‑affirming breast procedures, the policy directs use of CPT code 19318 for breast reduction/removal claims for transgender male and non‑binary members. Claims should not be submitted as CPT 19303 + 19350 for these indications per AMA/AAPC guidance.

When coding gender‑affirming breast procedures, use CPT 19318 for reduction/removal as the preferred code. The policy emphasizes correct code selection to align with billing guidance and prior authorization requirements.

Suction lipectomy (liposuction) alone is not covered as the sole treatment for gynecomastia because it is considered unproven for this indication. Surgical management must meet the policy's medical necessity criteria rather than relying on liposuction alone.

Procedures performed primarily to improve appearance or performed solely for psychological or psychosocial complaints are considered cosmetic and not medically necessary. Likewise, AFT for breast indications outside the listed reconstructive indications is considered cosmetic and excluded from coverage.

Transient lymphedema that resolves within six months after oncologic treatment and untreated lipedema (or lipedema without lymphatic dysfunction) are exclusions. Procedures for these conditions without documented lymphatic dysfunction or failed conservative therapy are not eligible for coverage.

Additional charges for robotic surgery will not be reimbursed. Inclusion or exclusion of codes in the policy is informational and does not guarantee member coverage or provider reimbursement; always verify member benefits and authorization requirements.

Liposuction, excision, or debulking performed for indications other than lipedema or lymphedema that do not meet the policy criteria are considered cosmetic and are not covered. Coverage for extremity procedures is limited to cases meeting the defined diagnostic and functional impairment criteria.

The policy specifically excludes liposuction or excision of adipose tissue for lipedema involving the head and neck region; such procedures in that anatomical area are not covered.

Excessive skin removal involving the arms is identified in the exclusions as not medically necessary and therefore not covered.

Autologous fat transfer (AFT) used for breast purposes outside the policy's specified reconstructive indications—such as purely aesthetic augmentation or contouring—is considered cosmetic and is not medically necessary under this policy.

Bariatric procedures are covered only for the indications and clinical criteria specified in the policy. Select Health does not cover bariatric surgery for other indications beyond those expressly listed.

Procedures and CPT codes explicitly listed in the 'Not covered' or 'Investigational/Unproven' sections are considered investigational/experimental/unproven for the indications addressed and are not covered; claims using those codes are at risk for denial.

Requests for services that do not meet all listed clinical criteria (for example, BMI thresholds, objective reflux testing, documented failure of conservative therapy, or required imaging/lab confirmation) will be denied as not meeting medical necessity.

Listing of CPT/HCPCS codes in this policy is for informational purposes only; inclusion or exclusion of a code does not guarantee coverage or imply reimbursement. Coverage is determined by the member's individual benefit plan and applicable payer policies.

The policy states that more than one breast augmentation (excluding autologous fat grafting) is considered cosmetic and not medically necessary. Medically necessary replacement of existing implants is not considered part of this cosmetic exclusion.

The policy identifies specific CPT codes as not covered for certain indications (for example, several adjustable gastric banding and endoscopic sleeve gastroplasty codes are listed as not covered/investigational); providers should use the covered CPT codes when requesting prior authorization for approved indications.

If gynecomastia surgery does not meet the policy's duration, severity (≥ Grade II), symptom, medication discontinuation, underlying cause correction, hormonal exclusion/treatment, and BMI < 30 requirements, the procedure is excluded and will not be covered.

The policy reiterates the exclusion of procedures performed primarily for a cosmetic purpose—services aimed at improving appearance or addressing psychosocial complaints without meeting medical necessity criteria are not covered.

Presence of listed contraindications (for example, transient lymphedema that will resolve, untreated lipedema without lymphatic dysfunction, pregnancy, active infection, uncontrolled comorbidities such as DVT, CHF, significant liver or renal disease, uncontrolled hypothyroidism, or venous insufficiency) makes a patient ineligible for coverage for the relevant procedures.

The policy repeats that excessive skin removal of the arms is considered not medically necessary and therefore excluded from coverage.

Billing Codes and Code Tables

Not covered: Investigational/Experimental/Unproven CPT Codes (athletic pubalgia)CPTNot Covered

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

HCPCS Codes (informational)HCPCS

No codes listed

CPT Codes (Covered per policy for listed conditions)CPTCovered

19499

Unlisted procedure, breast

HCPCS Codes (informational)HCPCS

No codes listed

Covered and Not Covered Procedures (no codes listed)mixed

No codes listed

Covered CPT CodesCPTCovered

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.
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/Experimental/Unproven) 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 / S CodeHCPCS

S2083

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

CPT Codes (informational)CPT

20999

Unlisted procedure, musculoskeletal system, general

HCPCS Codes (informational)HCPCS

C2618

Probe/needle, cryoablation

CPT Codes (Covered for gastric diversion area)CPTCovered

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

Codes mentioned (informational)mixed

No codes listed

Billing guidance for gender-affirming chest proceduresCPT

19318	Breast reduction/reduction mammaplasty (preferred for gender-affirming chest surgery per guidance)
19303	Complete mastectomy (guidance: should not be used for gender-affirming chest surgery when used with 19350)
19350	Nipple/areola reconstruction (guidance: should not be used in combination with 19303 for gender-affirming chest surgery)

CPT codes listed (GAMST section)CPT

00402	Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; reconstructive procedures on breast
00926	Anesthesia for procedures on male genitalia (including open urethral procedures); radical orchiectomy, inguinal
11980	Subcutaneous hormone pellet implantation
14040	Adjacent tissue transfer or rearrangement; defect 10 sq cm or less
14041	Adjacent tissue transfer or rearrangement; defect 10.1 to 30.0 sq cm
14301	Adjacent tissue transfer or rearrangement; defect 30.1 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 15

1/2

Covered CPT Codes (selected from listed GAMST pages)CPTCovered

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.
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, or 1% of body area of infants and children + each additional 1%.
15120	Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less.
15271	Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less.
15272	Each additional 25 sq cm wound surface area, or part thereof.

1–10 of 23

1/3

HCPCS / Durable Medical EquipmentHCPCSCovered

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

Gender-affirming breast procedure CPT codesCPTCovered

19318	Reduction mammaplasty
19303	Complete mastectomy (do not use for gender-affirming breast reduction/removal claims per guidance)
19350	Nipple/areola reconstruction (do not combine with 19303 for these claims)

Other listed CPT codes in gender-affirming procedures sectionCPT

00402	Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; reconstructive procedures on breast
00926	Anesthesia for procedures on male genitalia
11980	Subcutaneous hormone pellet implantation
14040	Adjacent tissue transfer or rearrangement
15100-15101	Split-thickness autograft, trunk/arms/legs; first 100 sq cm or less + additional
15734	Muscle, myocutaneous, or fasciocutaneous flap; trunk
15771	Grafting of autologous fat by liposuction technique, 50 cc or less
19304	Mastectomy, subcutaneous
19307	Mastectomy, modified radical
20926	Tissue grafts (autologous fat grafting)

1–10 of 12

1/2

HCPCS codes (GAMST)HCPCS

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 Codes (informational)HCPCS

No codes listed

Billing/Coding Information (informational)mixed

No codes listed

Covered CPT Codes (lymphatic procedures)CPTCovered

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

Covered CPT Codes (liposuction/excision and excess skin removal)CPTCovered

15832	Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
15833	Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg
15834	Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip
15878	Suction assisted lipectomy; upper extremity
15879	Suction assisted lipectomy; lower extremity

BMI thresholds — bariatric coverage

Primary BMI thresholdBMI > 40 kg/m2

Alternate BMI threshold with comorbidityBMI > 35 kg/m2 plus ≥1 inadequately controlled obesity‑related disease (eg, type 2 diabetes, hypertension, dyslipidemia, moderate‑to‑severe OSA, MASLD/MASH, cryptogenic cirrhosis, cardiovascular disease, pseudotumor cerebri, refractory GERD, severe osteoarthritis)

Provider Responsibilities, Prior Authorization, and Documentation

Prior Authorization

Verify benefits, eligibility & authorizations before care

Verify member benefits and eligibility with Select Health prior to providing services; benefits and eligibility are determined before medical and payment guidelines are applied and may affect coverage and reimbursement.

Contact Member Services or Provider Relations to confirm benefit-specific coverage and authorization requirements before scheduling procedures.

Prior Authorization

AFT covered only with covered breast reconstruction — verify auth

Autologous fat transfer (AFT) is covered only when performed in conjunction with medically necessary breast reconstruction for the listed indications; verify member benefits and obtain prior authorization as required.

Do not submit AFT for breast indications that are solely cosmetic — these are not covered.

Background and Scope

Varicose veins are included as a topic within the General Surgery table of contents; this policy set addresses multiple General Surgery topics and the excerpt provided confirms varicose vein procedures are among the policies catalogued in the Table of Contents.

Definitions and Key Terms

Autologous Fat Transfer (AFT)

AFT definitionAutologous fat transfer (AFT): harvesting a patient's adipose tissue and transferring it to the breast for reconstruction or augmentation

Harvest sites and volumesFat typically harvested from abdomen, hip, inner thigh; injected volumes per operation per breast range from 1.5–2.5 cc (nipple recon) to 30–460 cc (augmentation/defect correction)

Alternate termLipoinjection often performed in 1–3 staged procedures as needed

Lipoinjection — definition and staging

Lipoinjection definitionLipoinjection: harvesting and injecting autologous adipose tissue into the breast; commonly staged over 1–3 procedures

Typical harvest/usageUsed for nipple reconstruction, augmentation, and defect correction in breast reconstruction contexts

Policy Changes and Revision Notes

2025-06-07policy_reviewLatest

Policy last reviewed as listed in document metadata (last_review updated).

2024-08-20added

Added Section B - Criteria for Adolescents specifying behavioral assessment and documentation requirements for adolescent bariatric procedures.

2024-04-24revised

Policy Summary

PayerSelectHealth

PolicyVaricose Vein Procedures (General Surgery) — Coverage Criteria

Policy CodePolicy N/A

Change TypeMultiple material edits (criteria additions, clarifications, and revisions)

Effective DateN/A

Last ReviewJun 7, 2025

Next Review DateN/A

Key ActionVerify member benefits and obtain any required prior authorization before submitting requests for procedures.

SourceLink

On This Page

Asian descent adjustmentBMI thresholds reduced by 2.5 kg/m2 for patients of Asian descent

Short‑limb definition

Short‑limb definitionShort Roux limb defined as 150 cm or less (used in CPT 43846)

Long‑limb contrastLong‑limb (distal) Roux‑en‑Y described as >150 cm with greater malabsorptive effect and higher nutritional risk

Measurement method noteLong‑limb assessment measured backward from the ileocecal valve in policy description

Super‑obese BMI threshold

Super‑obese BMI thresholdBMI > 50 kg/m2 frequently cited as indication for malabsorptive procedures such as BPD/DS

Procedure contextBiliopancreatic diversion with duodenal switch (BPD/DS) advocated for very severe obesity and super‑obese cohorts

Risk noteMalabsorptive procedures associated with higher long‑term malnutrition and micronutrient deficiency risks

DeMeester score — abnormal threshold

DeMeester abnormal threshold> 14.7 (DeMeester score on 24–48 hour ambulatory pH probe considered abnormal)

Use in criteriaRequired objective evidence of reflux for gastric diversion: positive pH probe (DeMeester >14.7) OR EGD with esophagitis grade C/D or Barrett's

Calculator referenceDMS calculator referenced in policy (link provided in source) for score computation

Body Mass Index (BMI) — gastric diversion criteria

BMI requirement for gastric diversionBMI > 35 kg/m2 OR BMI < 35 with prior sleeve gastrectomy

Symptom requirementDaily reflux symptoms despite maximal PPI therapy required in gastric diversion criteria

Additional requirementDocumentation of failed medically managed weight loss required

Duration for DSM-5-TR gender dysphoria diagnosis

Minimum duration for DSM‑5‑TR gender dysphoria diagnosis>= 6 months (DSM‑5‑TR requirement for adolescents and adults)

Manifestation requirementDiagnosis manifested by at least two specified criteria (eg, incongruence with sex characteristics, desire to be other gender, desire to be treated as other gender)

WPATH interpretationWPATH SOC‑8 'marked and sustained' interpreted via DSM‑5‑TR 6‑month duration

Gynecomastia persistence — adolescent vs post‑pubertal

Adolescent persistence thresholdPubertal (adolescent) onset gynecomastia must persist ≥2 years to be eligible for surgery

Post‑pubertal persistence thresholdPost‑pubertal onset gynecomastia must persist ≥1 year to be eligible

Grade confirmationGlandular tissue must be documented and classified (Grade II or greater per ASPS) as part of criteria

Gender dysphoria duration

Gender dysphoria minimum duration>= 6 months (DSM‑5‑TR requirement; referenced across GAMST policy)

Diagnostic manifestationDiagnosis requires at least two DSM‑5‑TR criteria and clinically significant distress/impairment

WPATH SOC8 linkPolicy references WPATH SOC8 and interprets 'marked and sustained' via DSM‑5‑TR duration

BMI — gynecomastia requirement

BMI requirement for gynecomastia surgeryPatient BMI must be < 30 kg/m2 to meet coverage criteria

Grade requirementGynecomastia must be Grade II or greater per ASPS classification

Tissue confirmationGlandular breast tissue must be documented by physical exam and/or mammography

Duration of gynecomastia persistence

Adolescent persistenceAdolescent‑onset gynecomastia persisted ≥2 years

Post‑pubertal persistencePost‑pubertal‑onset gynecomastia persisted ≥1 year

Documentation requiredDuration must be documented along with exam/mammography and symptom history

Hormonal treatment duration before surgery

Hormonal treatment prior to surgeryWhen hormonal causes are present they must be treated for ≥12 months before surgery is considered

Laboratory exclusionHormonal causes must be excluded by appropriate labs (TSH, estradiol, prolactin, testosterone, LH) prior to surgery

Persistence despite correctionGynecomastia must persist despite correction of any underlying causes

Medication discontinuation period — gynecomastia

Medication discontinuation periodPotential gynecomastia‑inducing drugs/substances must be discontinued for ≥1 year when medically appropriate before surgery

Waiver provisionWaiver allowed with written statement from prescribing physician if medication is mandatory and cannot be changed

Documentation expectationDiscontinuation must be documented in medical record as part of coverage criteria

Eligibility thresholds — lymphatic procedures

ISL stage requirementUnilateral non‑pitting ISL Stage 2 or 3 required for liposuction coverage

Limb volume differenceLimb volume difference must exceed 25% for liposuction eligibility

BMI and conservative therapy for lymphovenous bypassBMI ≤ 35 and ≥1 month of CLT‑supervised conservative therapy (compression + other modality) required for lymphovenous bypass eligibility

Prior Authorization

Prior auth must document BMI, comorbidities, facility accreditation & evaluations

Obtain prior authorization demonstrating the patient meets required BMI thresholds, any applicable comorbidity criteria, facility accreditation or supervised MBSAQIP alternative status, tobacco abstinence, and multidisciplinary evaluation documentation.

Include documentation of BMI per policy thresholds (e.g., BMI > 40 or BMI > 35 + comorbidity).
Document facility MBSAQIP accreditation or supervision/proctoring arrangements.
Provide evidence of multidisciplinary evaluation within six months, including nutritional assessment and psychological assessment when indicated.

Prior Authorization

Prior authorization implied — use covered CPT codes for requests

Request prior authorization using the exact CPT codes for covered bariatric procedures and avoid codes listed as investigational/unproven; authorization is implied by selection of covered versus not-covered CPT codes.

Use covered CPT codes (e.g., 43645, 43775, 43846) when requesting authorization and do not submit investigational codes (e.g., 43770–43773, 43889).

Prior Authorization

Commercial prior auth: preop nutrition/psych docs & lifetime limits

Commercial plan prior authorization requires documentation of preoperative nutritional and psychological assessments (per criteria) and confirmation of lifetime coverage limits or allowed exceptions.

Include a preoperative nutritional assessment within one year (weight history; assessment of eating habits).
Provide preoperative psychological clearance when indicated (clarified for severe psychiatric history).
Be aware bariatric surgery is limited to one lifetime procedure except specified exceptions noted in policy.

Prior Authorization

Prior auth for cryoablation — follow plan-specific rules and coding

For cryoablation of desmoid tumors, obtain prior authorization under the applicable Select Health line (Commercial/CHIP or Medicare) and use the listed CPT/HCPCS codes; Medicare coverage follows CMS and may differ.

Commercial/CHIP: cryoablation is covered as medically necessary — include clinical documentation of prior medical therapy failures per policy.
Medicare: confirm CMS determinations; when CMS has not adopted a determination, the Select Health commercial policy may apply.

Prior Authorization

Get prior auth per member's plan — coverage depends on benefits

Obtain prior authorization because coverage determinations depend on the member's individual benefit plan and Select Health prior auth processes for the applicable line (Commercial, Medicare, Community Care).

Verify which Select Health line applies (Commercial/Medicare/Community Care) and follow that line's prior authorization requirements.

Prior Authorization

Verify benefits & obtain prior auth — plan-specific determination

Obtain prior authorization and verify benefits because coverage and eligibility are determined by the member's individual plan at the time of service.

Confirm member-specific coverage and any required authorizations before performing gender-affirming or other surgical procedures.

Prior Authorization

GAMST prior auth — include procedure, anesthesia & reconstructive codes (e.g., 19318)

Prior authorization is implied for covered gender-affirming surgical procedures and associated anesthesia and reconstructive CPT codes; include the specified CPT codes (e.g., 19318 for chest procedures) in authorization requests.

When requesting authorization for GAMST, list the applicable procedure, anesthesia, and reconstructive CPT codes as shown in the policy.

Prior Authorization

Plan-dependent prior auth — obtain per coverage criteria

Obtain prior authorization when coverage criteria apply; coverage and required authorizations are determined per individual benefit coverage and the policy's criteria.

Confirm that the requested procedure is listed and meets the plan filing (Colorado commercial plans have specific covered GAMST procedures).

Billing Rule

Use CPT 19318 for gender-affirming breast reduction/removal in auths & claims

For gender-affirming breast reduction/removal, include CPT 19318 on prior authorization and claims; do not code the procedure as CPT 19303 + 19350 per AMA/AAPC guidance.

Ensure prior authorization and billing reflect CPT 19318 for gender-affirming chest reconstruction/removal.

Prior Authorization

Include full set of listed CPT/HCPCS codes on prior auth when applicable

Include the full set of applicable CPT and HCPCS codes in prior authorization requests when the requested gender-affirming surgical services or devices require them; authorization should reflect all procedures and devices listed in the policy.

List surgical, anesthesia, reconstructive, and implant/prosthesis HCPCS codes as applicable to the request.

Prior Authorization

Prior auth required for CPT 19300 (gynecomastia mastectomy)

Prior authorization is required for mastectomy for gynecomastia (CPT 19300) and must demonstrate that the policy's medical necessity criteria are met.

Submit documentation showing duration, glandular confirmation, grade, pain, medication discontinuation, exclusion/treatment of hormonal causes, and BMI per policy.

Prior Authorization

Prior authorization required — ensure billing/coding align with covered indications

Obtain prior authorization per SelectHealth policy for covered indications; procedures are covered only when the policy's criteria are met and billing/coding align with the indication.

Ensure prior authorization submission includes clinical documentation demonstrating all applicable coverage criteria are satisfied.

Prior Authorization

Authorization implied when policy criteria apply — obtain prior to service

When the policy requires specific criteria for coverage, prior authorization is implied — obtain authorization before performing the service to confirm coverage.

Providers must confirm member-specific coverage and secure any required authorizations when criteria apply.

Prior Authorization

Prior auth for lipedema surgery — diagnostic, functional & failed conservative therapy docs

Prior authorization for lipedema surgical procedures (liposuction/excision/debulking and excess skin removal) must include documentation of diagnostic criteria, functional impairment, failed conservative therapy, and that the procedure will be performed in an appropriate surgical setting.

Provide clinical exam, photography, evidence of bilateral symmetric fat distribution, Stemmer's sign negative, documentation of ≥6 months failed conservative therapy, and functional impairment.
Confirm procedure setting (hospital or ambulatory surgical center) in the authorization request.

Step Therapy

Document conservative therapy tried before surgery (step therapy expectation)

Document that conservative therapies were tried first; for conditions like athletic pubalgia, initial treatment is conservative (rest, ice, NSAIDs, physical therapy, injections) and surgery is considered only after an adequate trial fails.

Include records of conservative management attempts and their duration in authorization requests for surgical consideration.

Documentation Required

Document attempts of non-surgical alternatives before approval

Document that all reasonable non-surgical alternatives were discussed and attempted prior to approval when the policy requires conservative therapy attempts.

Authorization should include evidence that alternatives were offered and attempted.

Step Therapy

Cryoablation requires documented failure of ≥2 lines of medical therapy

Cryoablation coverage is expected after failure of at least two lines of medical therapy; include prior treatment history showing failure of medical therapy in authorization and medical necessity documentation.

Provide details of prior systemic therapies tried and reasons for failure when requesting authorization for cryoablation.

Step Therapy

Document failure of medically managed weight loss before coverage

For bariatric coverage, document failed medically managed weight-loss efforts prior to authorization; include records demonstrating attempts at medically managed weight loss.

Include weight-loss program participation, duration, and outcomes in prior authorization materials.

Step Therapy

Six months continuous hormone therapy required before some GAMST unless contraindicated

For gonadectomy and certain genital reconstructive surgeries, document six months of continuous hormone therapy prior to authorization unless contraindicated or not desired by the member.

If hormone therapy is contraindicated or not desired, document the rationale in the authorization request.

Step Therapy

Document ≥1 year discontinuation of gynecomastia-inducing drugs/substances when appropriate

For gynecomastia, document discontinuation of potential causative drugs/substances for at least one year when medically appropriate before surgery is considered; include prescribing physician statements if discontinuation is not possible.

If medication cannot be stopped, include a written statement from the prescribing physician explaining necessity.

Step Therapy

Require ≥1 month of certified lymphedema therapy before delayed lymphovenous bypass

For delayed lymphovenous bypass, document at least one month of certified lymphedema therapist–supervised conservative therapy (compression and at least one modality) prior to authorization.

Include evidence of compliance with compression therapy and modalities such as manual lymphatic drainage or pneumatic pump use for a minimum of one month.

Step Therapy

Require ≥6 months conservative management documented before lipedema surgery

For lipedema surgical coverage, document failure of at least six months of conservative management (compression, non-calibrated segmental pump, or manual therapy) with lack of improvement prior to authorization.

Provide records showing conservative measures, duration (≥6 months), and lack of response in the authorization package.

Note

Verify payer-specific benefit rules (CMS/InterQual/State Medicaid) before auth

Verify member benefit plan and payer-specific coverage guidance prior to authorization; Medicare follows CMS determinations and Community Care typically aligns with state Medicaid policy — check CMS/State resources as needed.

Confirm whether CMS, InterQual, or state Medicaid rules supersede the commercial policy for the member.

Documentation Required

Preoperative multidisciplinary documentation (nutritional & psych) required

Ensure preoperative multidisciplinary documentation is available within six months of surgery, including nutritional assessment and psychological assessment when indicated; include weight history and assessment of eating habits.

Attach nutritional assessment (within one year) showing weight history and eating habits.
Include psychological clearance when required (severe psychiatric history or adolescent behavioral assessment).

Documentation Required

Preop nutritional assessment (weight history & eating habits) within 1 year

Include a preoperative nutritional assessment within one year of surgery that documents weight history and assesses eating habits as part of the required evaluation.

The revised criterion requires weight history and assessment of eating habits; evaluation of micronutrient deficiencies was removed.

Documentation Required

Preop psychological clearance required for severe psychiatric history; adolescent-specific rules apply

Obtain preoperative psychological clearance for members with severe psychiatric history per clarified criteria; for adolescents, clearance must be performed by a licensed behavioral health provider with pediatric/adolescent training and document decision-making maturity and assent.

For adolescents, include documentation of mature decision-making, ability to provide surgical assent, and family/social support.

Documentation Required

Adolescent psychological clearance by pediatric/adolescent licensed provider

For adolescent patients, behavioral assessment and psychological clearance must be performed by a licensed pediatric/adolescent–trained behavioral health provider and document elements required for surgical assent.

Document evidence of mature decision-making, awareness of risks/benefits, and ability to provide assent.

Documentation Required

Document prior treatment history and failure of medical therapy to support necessity

Include prior treatment history and objective evidence demonstrating failure of medical therapy when documenting medical necessity for procedures such as cryoablation and other interventions.

Provide records of prior systemic therapies and objective measures of disease progression or failure.

Documentation Required

Provide procedure‑specific clinical documentation (BMI, failed weight loss, objective reflux testing)

Provide required clinical documentation specific to the procedure: BMI documentation, evidence of failed medically managed weight loss, objective reflux testing (DeMeester >14.7) or EGD findings for reflux procedures, and other procedure‑specific tests as listed in the policy.

Include DeMeester score when applicable (>14.7 is abnormal).
Attach BMI records and failed weight-loss documentation for bariatric requests.

Documentation Required

Document age, provider qualifications, consults, diagnosis & consent capacity for GAMST

Document age, provider qualifications, necessary consults/referrals, diagnosis documentation (e.g., DSM-5-TR gender dysphoria), and capacity to consent where applicable for GAMST prior authorization.

Include referral letters from qualified HCPs and documentation aligning with DSM-5-TR and WPATH SOC-8 when requested.

Documentation Required

Referral letter must include identifying info, assessment, provider licensure, WPATH attestation

Include a referral letter that contains patient identifiers, assessment results and diagnoses, provider licensure/experience, statement that WPATH criteria have been met, and confirmation of informed consent.

Original or electronic signatures are acceptable on referral documents.

Documentation Required

Document DSM-5-TR Gender Dysphoria diagnosis with ≥6 months duration

For GAMST diagnostic documentation, support the DSM-5-TR Gender Dysphoria diagnosis with at least six months' duration and evidence of clinically significant distress or impairment per policy.

Align diagnostic documentation with DSM-5-TR criteria and reference WPATH SOC-8 as applicable.

Prior Authorization

Verify benefit coverage & provider alignment for Colorado GAMST

Verify member benefit allows GAMST and ensure provider meets policy qualification requirements before submitting authorization for Colorado commercial plans.

Confirm the requested procedure appears in the Colorado plan filing or meets policy #386 criteria.

Documentation Required

Document procedure rationale and use CPT 19318 for gender-affirming breast procedures

Document rationale for the procedure and use CPT 19318 for gender-affirming breast reduction/removal on prior authorization and claims; avoid coding with 19303 + 19350.

Provide procedure rationale and supporting clinical documentation when requesting authorization or submitting claims.

Documentation Required

Gynecomastia prior auth: include duration, glandular confirmation, grade, pain, med discontinuation, hormonal workup & BMI

For gynecomastia surgery prior authorization, include documentation of condition duration, physical exam or mammography confirming glandular tissue, ASPS Grade II+ classification, persistent pain despite analgesics, discontinuation of causative drugs for ≥1 year when appropriate, exclusion and treatment of hormonal causes for ≥12 months, and BMI <30.

Attach imaging or exam documentation confirming glandular tissue.
Include lab results and treatment records addressing hormonal causes.

Documentation Required

Attach attestation of tolerance for compression/PT and diagnostic tests for lymphatic reconstruction

Ensure required documentation and attestation for lymphatic reconstruction includes tolerance for post‑surgical compression/physical therapy, prior conservative therapy compliance, BMI documentation (≤35 for delayed reconstruction), and diagnostic imaging when indicated.

Provide lymphoscintigraphy, ICG, or MRI lymphangiography results as applicable.
Include attestations from treating lymphedema providers.

Note

Verify benefits; coding lists are informational — contact Provider Relations if unclear

Verify member benefits and note that coding lists in the policy are informational only; inclusion of codes does not guarantee coverage or reimbursement — contact Provider Relations or Customer Service with questions.

Do not assume inclusion of a CPT/HCPCS code in the policy equals benefit coverage for the individual member.

Documentation Required

Lipedema documentation required: exam, photos, Stemmer's sign, functional impairment & ≥6 months failed conservative therapy

For lipedema surgical authorization, include clinical exam and photography documenting bilateral symmetric thickened subcutaneous fat, Stemmer's sign negative, evidence of pain/hypersensitivity and easy bruising, functional impairment, and failed conservative therapy of ≥6 months.

Attach photographs, clinical exam notes, and documentation of failed conservative measures and their durations.

Note

Policy updates may change coverage — confirm current policy and benefits

Policies are subject to change without notice; verify current policy language and member benefits before submitting authorization requests to avoid denials.

Policy updates may alter coverage, criteria, or coding guidance.

Denial Risk

AFT billed outside covered breast indications is cosmetic — risk of denial

Autologous fat transfer billed for breast indications outside the listed covered indications is considered cosmetic and not covered; prior authorization will be denied for cosmetic AFT requests.

Do not submit authorization for AFT when intended solely for cosmetic breast enhancement — these are excluded.

Denial Risk

Facility MBSAQIP accreditation/supervision required — denial risk if absent

Ensure procedures are performed at MBSAQIP-accredited facilities or supervised alternatives per policy; lack of required facility accreditation or supervision may trigger denial.

Include facility accreditation status or proctoring documentation with the authorization request.

Denial Risk

Denial risk for investigational/unproven CPT codes — avoid using listed not-covered codes

Claims for procedures listed as investigational/unproven (codes in the Not Covered list) are at risk for denial; do not request authorization or submit claims using those CPT codes for the indicated conditions.

Investigational codes include 43770–43773, 43842–43843, 43847, 43886–43889, 43999, 43659 among others listed.

Denial Risk

Lifetime bariatric surgery limit — denials expected if >1 unless policy exceptions apply

Bariatric surgery is generally limited to one lifetime procedure; requests for additional bariatric procedures will be denied except for specified exceptions (e.g., initial BMI >60 allowing biliopancreatic bypass after sleeve, or prior laparoscopic gastric banding).

Document if the member meets an exception to the one-lifetime limit when requesting authorization.

Note

Medicare coverage follows CMS — verify CMS determinations before requesting auth

For Medicare members, coverage follows CMS determinations; absence of a CMS determination or differing CMS guidance may affect authorization and coverage decisions.

Check CMS/NCD/LCD resources and cite relevant Medicare determinations when submitting prior authorization for Medicare members.

Denial Risk

Objective reflux testing required (DeMeester >14.7 or EGD grade C/D) — denial risk if absent

Objective evidence of reflux is required for gastric diversion coverage; lack of DeMeester score >14.7 or EGD findings of grade C/D esophagitis or Barrett's esophagus may trigger denial.

Include 24–48 hour ambulatory pH probe results (DeMeester >14.7) or EGD documentation when requesting authorization for gastric diversion.

Note

Benefit verification required — confirm plan-specific coverage to avoid denial

Verify benefit eligibility prior to service; coverage and reimbursement depend on the member's individual benefit plan and failure to verify may result in denial or nonpayment.

Confirm coverage, authorizations, and any member cost-sharing responsibilities before providing services.

Denial Risk

Denial risk if GAMST minimum criteria (age, HCP assessment, diagnosis, consent) not met

Failure to meet minimum policy criteria (e.g., age, qualified HCP assessment, documented gender dysphoria duration, capacity to consent) may result in denial for gender-affirming surgical services.

Ensure all listed minimum criteria are documented before submitting prior authorization for GAMST.

Denial Risk

Coding-triggered denial risk — use CPT 19318, not 19303 + 19350, for gender-affirming chest procedures

Do not code gender-affirming breast reduction/removal as CPT 19303 + 19350; use CPT 19318 per AMA/AAPC guidance to avoid coding-triggered denials.

Update claim and authorization coding to CPT 19318 for gender-affirming chest reconstruction/removal.

Denial Risk

Documentation-triggered denial risk for gynecomastia — meet all subcriteria a–g

Gynecomastia surgery authorization may be denied if documentation does not show required persistence, grade (Grade II+), pain, discontinuation of causative medications, correction/exclusion of underlying causes, hormonal workup/treatment, and BMI <30.

Provide all subcriterion documentation (a–g) when requesting authorization for gynecomastia surgery to avoid denial.

Denial Risk

Liposuction alone for gynecomastia is excluded — risk of denial

Suction lipectomy (liposuction) as sole treatment for gynecomastia is not covered; submitting claims for liposuction alone risks denial as cosmetic/unproven.

If submitting for gynecomastia treatment, ensure the approach aligns with covered surgical methods and policy exclusions.

Denial Risk

Contraindications (e.g., transient lymphedema, uncontrolled comorbidities, infection, pregnancy) preclude coverage

Presence of listed contraindications (e.g., transient lymphedema resolving within six months, untreated lipedema without lymphatic dysfunction, uncontrolled comorbidities, pregnancy, active infection) precludes coverage and will trigger denial.

Review the contraindication list and include documentation confirming none apply when requesting authorization for lymphatic or lipedema procedures.

Denial Risk

Denial risk if documentation does not meet all coverage criteria

Services may be denied if the submitted documentation does not demonstrate that all applicable coverage criteria are met for the requested indication.

Ensure authorization packages include complete clinical evidence mapping to each policy criterion.

Denial Risk

Cosmetic exclusion — liposuction/excision outside lipedema/lymphedema criteria will be denied

Liposuction/excision/debulking for indications other than lipedema or lymphedema that do not meet policy criteria are considered cosmetic and will be denied.

Do not request authorization for cosmetic liposuction/excision outside the covered lipedema/lymphedema criteria.

Coverage contextPolicy limits AFT coverage to specified reconstructive indications; other uses considered cosmetic (not covered)

Morbid obesity — definition

Morbid obesity definitionMorbid obesity defined as BMI > 40 kg/m2

Clinical impactAssociated with significant health complications and shortened life span (eg, HTN, diabetes, CHD, stroke, osteoarthritis)

Surgical considerationPatients often considered for bariatric surgery after failed non‑surgical weight‑loss attempts

Short‑limb Roux‑en‑Y gastric bypass — definition

Short‑limb RYGB contextShort‑limb Roux‑en‑Y gastric bypass (Roux limb ≤150 cm) considered standard RYGB and listed among covered bariatric procedures (CPT 43846)

Comparator statusShort‑limb RYGB considered the gold‑standard comparator for malabsorptive procedures

Coding noteCPT 43846 describes gastric bypass with short limb (150 cm or less)

Long‑limb (distal) Roux‑en‑Y — definition

Long‑limb (distal) RYGB definitionLong‑limb (distal) Roux‑en‑Y: Roux limb measured farther downstream (>150 cm) with Y‑connection formed closer to distal small bowel, increasing malabsorption and nutritional risk

Clinical tradeoffGreater weight loss traded against higher rates of electrolyte and nutritional complications

Measurement methodMeasurement described as measured backward from the ileocecal valve

BPD/DS — definition and context

BPD/DS definitionBiliopancreatic diversion with duodenal switch (BPD/DS): malabsorptive operation with sleeve gastrectomy and short common channel, associated with greater weight loss and higher long‑term malabsorption risk

Indication nicheOften considered for very severe obesity (eg, BMI > 50 kg/m2) and in revisional settings

Nutritional monitoringAssociated with long‑term micronutrient/protein deficiencies requiring supplementation and follow‑up

Revision procedures / not considered revision — clarifications

Revision procedures clarificationPolicy clarifies situations not considered revisions (eg, additional procedures allowed after initial sleeve for BMI > 60 or prior banding), and affirms single lifetime coverage with specific exceptions

Lifetime limit noteBariatric surgery generally limited to one lifetime procedure except specified exceptions (initial BMI > 60 allowing BPD/DS after sleeve, or prior laparoscopic banding)

Credentialing updateFacilities undergoing MBSAQIP recruitment or pre‑credentialing allowed for bariatric procedures per revisions

Extra‑abdominal desmoid tumors — definition

Extra‑abdominal desmoid tumor definitionLocally aggressive fibromatoses occurring outside the abdominal cavity for which local ablative therapy such as cryoablation may be considered

Cryoablation roleCryoablation considered for progressive disease after ≥2 lines of medical therapy with good disease control rates

Size limitationEfficacy reduced for larger tumors or tumors adjacent to critical structures where complete ablation may risk injury

Roux‑en‑Y gastric bypass (RYGB) — definition

RYGB definitionRoux‑en‑Y gastric bypass (RYGB): gastric pouch drained by a Roux limb from the proximal jejunum to treat obesity and associated GERD

Therapeutic effectRYGB associated with alleviation of GERD symptoms compared with lifestyle modification

Coding notePolicy lists short‑limb RYGB among covered CPT codes (eg, 43846 described for short limb ≤150 cm)

DeMeester score (DMS) — definition

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

Use in gastric diversion criteriaDeMeester >14.7 accepted as objective evidence of pathologic reflux for diversion candidacy

Reference linkPolicy references an online DeMeester score calculator for computation

Gender dysphoria — policy definition

Gender dysphoria definitionMarked and sustained incongruence between experienced/expressed gender and assigned gender causing clinically significant distress or impairment

DSM‑5‑TR criteriaDiagnosis requires at least 6 months duration and manifestation of specified criteria (≥2 in adolescents/adults)

GAMST scopeGAMST encompasses medical, psychiatric, and surgical interventions as a spectrum of care

Gender dysphoria (DSM‑5‑TR) — definition & HCP requirements

DSM‑5‑TR gender dysphoria specificsMarked incongruence lasting ≥6 months, manifested by two or more specified criteria (eg, desire to be rid of sex characteristics; desire to be treated as other gender)

Qualified HCP characteristicsQualified healthcare professional: Master's or equivalent, licensure, DSM/ICD competence, ability to assess co‑occurring mental health and capacity to consent, and experience with gender diversity

WPATH linkWPATH SOC‑8 referenced as standard informing HCP minimum requirements and 'marked and sustained' interpretation

Qualified Healthcare Professional — definition

Qualified HCP definitionClinician with at least a Master's degree, appropriate licensure/credentials, competence in DSM/ICD diagnostics, ability to assess capacity to consent and co‑occurring mental health conditions, and experience with gender diversity

Pediatric/adolescent additionsFor children/adolescents, additional training/expertise in child/adolescent mental health, gender identity development, and assessing assent/consent is required

Continuing educationOngoing education and engagement with multidisciplinary consultation recommended

GAMST — definition

GAMST summaryGender‑affirming medical and surgical treatment (GAMST) is a spectrum of interventions for gender dysphoria and not a single procedure

Diagnostic foundationRequires DSM‑5‑TR diagnosis of gender dysphoria and consideration of WPATH SOC‑8 standards

Eligibility elementsPolicy requires age, qualified HCP assessments, referrals, capacity to consent, and documented social transition per criteria sections

Gynecomastia — definition & grading

Gynecomastia definitionExcessive development of male mammary glands due mainly to ductal proliferation with periductal edema; may be physiologic in adolescence

Grade scaleASPS/McKinney/Simon/Hoffman‑Kohn grading used (Grade I–IV) to classify severity; Grade II+ required for coverage

Treatment contextSurgical removal considered when persistence, grade, pain, medication cessation, hormonal exclusion/treatment, and BMI criteria met

Immediate and Delayed Lymphatic Reconstruction — definitions

Immediate Lymphatic Reconstruction (ILR)Prophylactic microsurgical lymphovenous bypass performed at time of nodal dissection intended to prevent lymphedema

Delayed reconstructionDelayed lymphovenous bypass performed after diagnostic confirmation and prior conservative therapy

Related proceduresMicrosurgical techniques include free flaps with microvascular anastomosis, lymphangiography, and use of operating microscope (CPTs listed)

Lipedema — definition and clinical features

Lipedema definitionPainful disorder in women with abnormal bilateral deposition of subcutaneous adipose tissue of lower extremities causing pain, bruising, and functional impairment

Diagnostic featuresDiagnosis by clinical exam and photography: bilateral symmetric thickened fat, pain/hypersensitivity, easy bruising, Stemmer's sign negative, absence of pitting edema unless comorbid lymphedema

Conservative therapy requirementFailed conservative management (≥6 months) required before surgical interventions like liposuction or excision

Stemmer's sign negative — definition

Stemmer's sign negativeA fold of skin can be pinched and lifted up at the base of the second toe or base of the middle finger; negative sign helps distinguish lipedema from lymphedema

Diagnostic implicationStemmer's sign negative is one required feature for lipedema diagnosis in policy

Use in documentationPolicy requires clinical exam and photography documenting Stemmer's sign among other features

Modified facility credentialing rules to allow bariatric surgery at facilities undergoing recruitment or pre-credentialing for MBSAQIP accreditation and updated adolescent preoperative psychological clearance elements.

2024-01-16clarified

Clarified preoperative psychological clearance requirement for members with specified severe psychiatric conditions (criterion #8a).

2023-11-29added

Clarified lifetime coverage and revision policy for bariatric surgery, affirming one lifetime procedure with specified exceptions (initial BMI >60 or prior laparoscopic gastric banding).

2023-11-07added

For Commercial Plan Policy, added AFT as a covered option for breast augmentation when performed for symmetry after treatment of contralateral breast cancer (criterion #3).

2023-04-03revised

Modified preoperative nutritional assessment requirements by removing micronutrient deficiency evaluation from criterion #7.

2023-03-09revised

Modified criteria #7 to specify required elements in the preoperative nutritional assessment (weight history; assessment of eating habits; earlier wording included micronutrient evaluation).