CurrentUnitedHealthcarePolicy CS007KS.01

Bariatric Surgery (for Kansas Only)

State-specific UnitedHealthcare medical policy for bariatric surgery applicable only to members in Kansas. Directs readers to the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual for medical necessity clinical coverage criteria and lists relevant procedure and diagnosis codes for reference.

Policy Summary

PayerUnitedHealthcare

PolicyBariatric Surgery (for Kansas Only)

Policy CodePolicy CS007KS.01

Change TypeNew policy (06/01/2025); reference link update (04/01/2026)

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionProviders must refer to and document compliance with the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual for clinical medical necessity criteria for bariatric surgery.

POLICY UPDATE CHANGES

New Medical Policy effective 06/01/2025.

04/01/2026: Updated reference link for related policy 'Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for Kansas Only)'.

KansasGeographic scope

Kansas Medicaid ManualMedical necessity source

ManyProcedure codes listed

Coverage Summary

Scope: State-specific UnitedHealthcare medical policy for Bariatric Surgery (Kansas Only). Policy Number: CS007KS.01. Effective Date: June 1, 2025; Last review: April 1, 2026.

Compact policy details

Geographic scopeState-specific (Kansas)

Medical necessity sourceReferenced externally — Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual

Coverage stanceInformational

FDA approvals referencedORBERA (2015); Lap-Band (2001; updated 2011); OverStitch (510k 2018); TransPyloric Shuttle (PMA 2019)

Medical-Necessity Criteria

Coverage Rationale / Medical Necessity

Refer to Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual for medical necessity clinical coverage criteria.

ALL of the following

This policy applies only to the state of Kansas.
For medical necessity clinical coverage criteria for bariatric surgery, refer to the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual (external document).
External reference: Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual.

ref": "b1_0

title": "Coverage Rationale / Medical Necessity

Provider Actions

Documentation Required

Follow Kansas Medicaid Medical Necessity Criteria

Providers must refer to and document compliance with the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual for clinical medical necessity criteria for bariatric surgery; coverage decisions are governed by federal, state, or contractual requirements.

Providers must refer to and document compliance with the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual for clinical medical necessity criteria for bariatric surgery.
Coverage and payment decisions are governed by federal, state, or contractual requirements; check applicable benefit terms.

Billing Rule

Code reporting clarification for sleeve gastrectomy

Report laparoscopic sleeve gastrectomy with CPT code 43775 rather than the unlisted CPT code 43659.

Affected CPT codes: 43775, 43659
Policy preference: use CPT 43775 to report laparoscopic sleeve gastrectomy instead of unlisted CPT 43659.

Coding

Procedure codes referenced (informational only)CPT

0813T	Esophagogastroduodenoscopy, flexible, transoral, with volume adjustment of intragastric bariatric balloon.
43290	Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon.
43291	Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s).
43644	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less).
43645	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption.
43647	Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum.
43648	Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum.
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.

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Coding guidance in this policy is informational. Emphasize that CPT 43775 should be used to report laparoscopic sleeve gastrectomy rather than the unlisted CPT code 43659; this is a coding clarification and billing rule (see provider_actions).

Coding decisions and final billing determinations may be governed by the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual and applicable federal, state, or contractual requirements, so clinicians and billing staff should follow Kansas Medicaid guidance where applicable.

Background

UnitedHealthcare provides state-specific information for Kansas members about bariatric surgery and includes FDA device approvals relevant to bariatric devices for informational purposes. Examples referenced include FDA approvals for intragastric balloons (ORBERA), gastric bands (Lap-Band), and surgical stapling/endoscopic suturing devices (e.g., Endo Gia staples, OverStitch), and devices such as the TransPyloric Shuttle.

The policy clarifies coding guidance (codes listed are informational) and lists relevant CPT procedure codes for reference. It directs clinicians to the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual for medical necessity clinical coverage criteria and notes that UnitedHealthcare uses InterQual and approved UnitedHealthcare Medical Policies when applicable.

FDA approvals referencedORBERA (2015), Lap-Band (2001, 2011 updates), OverStitch (510k 2018), TransPyloric Shuttle (PMA 2019)

Revision History

06/01/2025added (is_material)