Bariatric Surgery (for Idaho Only)
This policy governs medical necessity and coverage of bariatric surgical procedures for members in Idaho, including Idaho Medicaid Plus plans. It specifies which procedures are proven and medically necessary, which are unproven/not medically necessary, and state-specific referral to the Idaho Medicaid Provider Handbook for detailed clinical criteria.
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.
Removed coverage criteria for biliopancreatic diversion/duodenal switch, gastric bypass (including robotic-assisted), adjustable gastric banding for individuals ≥18, and sleeve gastrectomy.
Added CPT code 43999 to applicable codes.
Noted that CPT codes 0813T, 43290, and 43647 are not on the Idaho Medicaid Fee Schedule and therefore may not be covered by Idaho Medicaid; refer to Idaho Medicaid Provider Handbook for non-covered/excluded services.
Updated Description of Services, Clinical Evidence, FDA, and References sections to reflect current information; archived previous policy version CS007ID.B.
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