Bariatric Surgery (for Idaho Only)

Coverage Summary

State-specific policy for Idaho (applies to Idaho including Idaho Medicaid Plus) addressing bariatric surgery medical necessity, coverage, and coding (Policy CS007ID.C, effective May 1, 2026). This is Part 1 of 6 and provides procedural coverage lists, criteria for planned two-stage and revisional bariatric surgeries, explicit exclusions (unproven/not medically necessary procedures), documentation expectations, definitions, and an applicable CPT/procedure code list with Idaho-specific notes (including codes not on the Idaho Medicaid Fee Schedule).

High-level coverage stance: lists specific bariatric procedures identified as proven and medically necessary (e.g., biliopancreatic diversion/duodenal switch; gastric bypass including robotic-assisted; adjustable gastric banding for individuals ≥ 18 years; sleeve gastrectomy) and enumerates numerous procedures/interventions considered unproven / not medically necessary. The policy also details criteria for planned two-stage procedures (initial BMI threshold and timing) and indications that make revisional surgery medically necessary.

Procedural and administrative content includes: criteria for two-stage procedures (initial BMI ≥ 50 kg/m2, second stage within 2 years, compliance requirements), revisional surgery indications and required documentation (e.g., attempted band manipulation for slippage), CPT/code guidance (including instruction to use CPT 43775 for laparoscopic sleeve gastrectomy), and notation of CPT codes 0813T, 43290, and 43647 as not on the State of Idaho Medicaid Fee Schedule (may not be covered). The policy’s stats summary lists ~40 CPT codes and enumerates numeric counts for covered vs unproven procedures.

Key thresholds and policy facts

Initial BMI for two-stage procedure>= 50 kg/m2

Second stage timingSecond stage occurs within 2 years of primary bariatric surgery

Age for adjustable gastric banding coverage>= 18 years

Effective date2026-05-01

Policy numberCS007ID.C

State applicabilityApplies to Idaho (including Idaho Medicaid Plus)

Medical Necessity Criteria

Covered Bariatric Procedures (Non-State-Specific)

The following bariatric surgical procedures are proven and medically necessary for treating obesity:

Covered Bariatric Procedures (Non-State-Specific) - Top Level

Biliopancreatic diversion / BPD-DS: Biliopancreatic diversion/biliopancreatic diversion with duodenal switch
Gastric bypass (includes robotic-assisted gastric bypass)
Adjustable gastric banding (age): Adjustable gastric banding (using open or laparoscopic approaches) for individuals ≥ 18 years of age>= 18 years
Refer to FDA section for additional information

Not Medically Necessary / Unproven Procedures

Not Medically Necessary / Unproven Procedures for Treating Obesity

The following procedures are unproven and not medically necessary for treating obesity due to insufficient evidence of efficacy:

Not Medically Necessary / Unproven Procedures - Top Level

Revisional for other indications: Revisional Bariatric Surgery for any other indication than those listed above
Bariatric as primary for non-obesity: Bariatric surgery as the primary treatment for any condition other than obesity
BAE: Bariatric artery embolization (BAE)

CPT / Procedure Codes

Applicable CPT / Procedure Codes (reference list)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

1–10 of 30

1/3

Codes Not on State of Idaho Medicaid Fee Schedule (asterisked)CPT

0813T	Not on State of Idaho Medicaid Fee Schedule (asterisked in document)
43647	Not on State of Idaho Medicaid Fee Schedule (asterisked in document)

CPT codes noted as not on State of Idaho Medicaid Fee Schedule (may not be covered by Idaho Medicaid)CPTNot Covered

0813T	0813T (not on the State of Idaho Medicaid Fee Schedule)
43290	43290 (not on the State of Idaho Medicaid Fee Schedule)
43647	43647 (not on the State of Idaho Medicaid Fee Schedule)

Provider Actions & Billing Rules

Documentation Required

Medical record documentation required

Patient medical record must contain documentation that fully supports medical necessity for the requested services, including relevant medical history, physical exam, diagnostic test results, and other supporting documentation. Records must be legible, maintained in the patient's medical record, and made available upon request.

Documentation Required

Adjustable gastric band slippage correction attempts

For revisional surgery related to adjustable gastric band migration/slippage, medical records must document that manipulation or adjustment attempts to correct band slippage were performed prior to revision. Ensure operative and clinic notes describe these attempts and their outcomes.

43771
43772

Background and Clinical Evidence

Background and applicability: the policy applies only to the state of Idaho, including Idaho Medicaid Plus, and advises referring to the Idaho Medicaid Provider Handbook (Chapter 5.10) for state-specific medical necessity clinical coverage criteria.

Bariatric surgical approaches are summarized as two broad mechanisms: restrictive procedures (reduce stomach capacity to limit intake) and malabsorptive procedures (alter intestinal absorption). Procedures may have restrictive, malabsorptive, or mixed features and can be performed via open, laparoscopic, robotic, or endoscopic approaches.

Goals of surgery: to induce substantial weight loss, improve or resolve obesity-related comorbidities, and improve quality of life. The policy references accreditation by the MBSAQIP as the national accreditation standard for bariatric surgical centers and notes multidisciplinary assessment prior to revisional surgery.

Revisional surgery terminology (definitions used in the policy): conversion (change from one bariatric approach to a different type of procedure), corrective (correct or modify anatomy or device to achieve original outcome or address complication), restoration/reversal (restore original anatomy). These terms are used throughout the policy to describe indications and coverage for secondary procedures.

Evidence / Study	Key finding
Ikramuddin et al. 2018 (RCT follow-up)
RYGB vs intensive medical management: at 5 years RYGB had higher composite triple end point (23% vs 4%) and higher % achieving HbA1c <7% (55% vs 14%) but more serious adverse events (66 vs 38).
LSG long-term data (Clapp et al. 2018; Felsenreich 2017; Flølo 2017)
Sleeve gastrectomy shows substantial early weight loss but notable long-term recidivism (~27.8% at ≥7 years) and revision rate (~19.9%); GERD/new Barrett’s and conversions to RYGB reported in long-term follow-up.
Intragastric balloon (IGB) trials (Spatz/Orbera/REDUCE/Obalon)
RCTs and registries show short-term clinically significant weight loss (e.g., Spatz %TBWL 15% at 32 weeks; REDUCE dual balloon %EWL ~25% at 24 weeks; Orbera meets ASGE PIVI), but most patients regain weight after removal and long-term clinical significance is unclear; adverse events and early removals reported.
Bariatric artery embolization (BAE) (Reddy 2020, meta-analyses)
Small sham-controlled RCT showed modest TBWL at 6 months (7.4 kg vs 3.0 kg); case-series meta-analyses report ~8.7 kg at 12 months but evidence insufficient and safety signals reported—considered investigational.
Gastric electrical stimulation (GES/CLGES) (Morales-Conde 2018; Paulus 2020; systematic reviews)
Early feasibility and cohort studies report modest weight loss (e.g., %TBWL ~14% at 12 months) and acceptable safety in small studies, but RCT-level durable evidence lacking; authors call for larger RCTs.
Endoscopic sleeve gastroplasty (ESG, OverStitch) (MERIT RCT, systematic reviews)
RCTs and meta-analyses show ESG produces meaningful weight loss vs lifestyle alone (%TWL ranges across studies) with SAE rates ~2% but generally less weight loss than surgical LSG; longer-term comparative data limited.
Endoscopic gastrointestinal liners (DJBL/EndoBarrier) (RCTs/observational)
DJBL yields significant weight/metabolic improvements while in place but has high AE rates including serious events (hepatic abscess, GI hemorrhage) and benefits often lost after removal; evidence insufficient for routine use.
Transoral endoscopic devices (TPS, GI bypass devices)
Feasibility and single-arm studies report large %EWL/%TWL at 6–12 months (e.g., TPS, gastrointestinal bypass sleeve), but RCT evidence limited and longer-term confirmation needed.
Stomach aspiration therapy (AspireAssist)
Observational and RCT-extension data report sustained weight loss up to 4 years (~17–18% TWL) with pooled SAE ~4.1%; evidence limited by study designs and patient selection.
Revisional/one-anastomosis/SADI concerns (OAGB/MGB, SADI-S/SADS)
Systematic reviews and prospective studies suggest OAGB/SADI may achieve substantial EWL and comorbidity remission but carry concerns for GERD, diarrhea, malabsorption, and nutritional disorders; long-term comparative data are limited and safety/nutrition issues noted.

Glossary / Definitions:

Body Mass Index (BMI) — A person's weight in kilograms divided by the square of height in meters. The policy references standard adult BMI classification ranges (e.g., ≥ 40 kg/m2 = Obesity Class III) and pediatric/adolescent severe obesity classifications per ASMBS guidance.

Los Angeles (LA) Classification of Oesophagitis — Grades A–D defined by mucosal-break size and circumferential involvement: Grade A (mucosal break ≤ 5 mm not extending between folds), Grade B (> 5 mm not extending between folds), Grade C (continuous mucosal break between tops of two or more folds involving < 75% circumference), Grade D (mucosal break involving ≥ 75% circumference).

Revision History

2026-05-01added (MATERIAL)Latest

Added instruction to refer to the Idaho Medicaid Provider Handbook, Medical Services, Chapter 5.10 for medical necessity clinical coverage criteria for bariatric surgery using one of the procedures identified in the policy.

2026-05-01removed (MATERIAL)

Removed coverage criteria for biliopancreatic diversion/duodenal switch, gastric bypass (including robotic-assisted), adjustable gastric banding for individuals ≥ 18 years, and sleeve gastrectomy from Non-State-Specific Criteria.

2026-05-01added (MATERIAL)