CurrentUnitedHealthcarePolicy CS007KS.01

Bariatric Surgery (for Kansas Only)

Defines UnitedHealthcare's medical policy for bariatric surgical procedures for members in Kansas and references the Kansas Medical Assistance Program criteria. Affects providers submitting coverage requests and claims for bariatric procedures in Kansas.

Policy Summary

PayerUnitedHealthcare

PolicyBariatric Surgery (for Kansas Only)

Policy CodePolicy CS007KS.01

Change TypeNew Medical Policyminor clarifications

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionFollow the Kansas Medical Assistance Program criteria and provide documentation aligned with InterQual when requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

New Medical Policy

Updated reference link for related Minimally Invasive Procedures policy

Kansas-onlystate applicability

CS007KS.01policy identifier

2025-06-01effective date

Kansas MAP Manualclinical coverage source

Coverage Criteria

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Medical necessity per external criteria

Covered when ALL of the following are met per referenced sources

Primary criteria source: Medical necessity clinical coverage criteria for bariatric surgery are those in the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual.

Providers must follow the Kansas manual for specific numeric criteria (e.g., BMI thresholds, comorbidity requirements) referenced by this policy.

UnitedHealthcare primary criteria: UnitedHealthcare uses InterQual for primary medical/surgical criteria; if InterQual does not have applicable criteria, UnitedHealthcare may also use UnitedHealthcare Medical Policies approved by the Kansas Department of Health and Environment.

When requesting authorization, providers should expect review against InterQual and the Kansas manual; documentation should reference applicable federal, state, or contractual benefit plan requirements.

Documentation and benefit governance: Coverage determinations must reference and comply with federal, state, or contractual requirements for benefit plan coverage; in the event of conflict, those requirements govern.

This policy is informational and does not by itself guarantee coverage; providers must check applicable benefit plan terms.

Coding and Billing

Applicable CPT codes (selection)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).

Additional Applicable CPT codesCPT

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.
43774	Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components.
43775	Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy).
43843	Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty.
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.
43847	Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption.
43848	Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure).

1–10 of 13

1/2

Neurostimulator and related CPT codesCPT

43882	Revision or removal of gastric neurostimulator electrodes, antrum, open.
43886	Gastric restrictive procedure, open; revision of subcutaneous port component only.
43887	Gastric restrictive procedure, open; removal of subcutaneous port component only.
43888	Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only.
64590	Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver.
64595	Revision or removal of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, with detachable connection to electrode array.
64999	Unlisted procedure, nervous system.

Coding clarificationCPT

43775 (clarification)

Use CPT 43775 to report laparoscopic sleeve gastrectomy rather than unlisted CPT 43659.

Device BMI indications — examples and thresholds for devices

ORBERA Intragastric BalloonIndicated as an adjunct to weight reduction in obese adults with BMI ≥30 and ≤40 kg/m²; maximum placement six months; to be used with a long-term supervised diet and behavior modification program after failure of conservative strategies.

LAP-BAND / Adjustable Gastric Band (2001 FDA PMA)Approved for severely obese adults: BMI ≥40 kg/m², or BMI ≥35 kg/m² with one or more severe comorbid conditions (or ≥100 lb over ideal weight per 1983 tables); indicated after failure of conservative treatments.

Lap-Band (2011 FDA expansion)FDA approval expanded to include patients with BMI ≥40 kg/m² or patients with BMI ≥30 kg/m² with one or more obesity-related comorbid conditions (e.g., diabetes, hypertension).

Adjustable band contraindicationAdjustable gastric bands are contraindicated in patients younger than 18 years of age.

TransPyloric Shuttle (example)Indicated for adults with BMI 35.0–40.0 kg/m² or BMI 30.0–34.9 kg/m² with one or more obesity-related comorbid conditions; intended to be used with a diet and behavior modification program.

Provider Actions and Authorization

Billing Rule

Coding inclusion not guarantee of coverage

Listing a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Providers should verify member benefit coverage and payment eligibility prior to delivery of services.

Documentation Required

Coverage decision documentation

Providers must document coverage decisions in the medical record and ensure documentation aligns with the terms of the federal, state, or contractual benefit plan. When determining coverage, reference the applicable federal, state, or contractual requirements, including the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual when relevant. In the event of a conflict between this Medical Policy and federal, state, or contractual requirements, the federal, state, or contractual requirements govern. Maintain records supporting medical necessity, prior authorization approvals, conservative therapy attempts (when required), device indications, and any utilization of InterQual® or other referenced clinical criteria.

Prior Authorization

Conservative therapy expectation for device procedures

Devices and device-based procedures referenced in this policy (for example, intragastric balloons such as the ORBERA System) are intended to be used as adjuncts to comprehensive weight management and are indicated only after failure of conservative weight reduction strategies. Conservative therapy expectations include documentation of trials of supervised diet, exercise, and behavior modification programs and other noninvasive weight-loss interventions as required by the applicable benefit plan or state program. For devices with limited placement durations or FDA-specified use (e.g., ORBERA maximum 6-month placement), document adherence to the device-specific indication and program requirements.

Definitions

ORBERA System — intragastric balloon indications and use

Indication (population)ORBERA is indicated as an adjunct to weight reduction in obese adults with BMI ≥30 and ≤40 kg/m² who have failed conservative weight reduction strategies.

Adjunctive requirementsTo be used in conjunction with a long-term supervised diet and behavior modification program designed to increase likelihood of long-term weight loss and maintenance.

Placement durationMaximum placement period of six months.

Conservative therapy requirementIndicated for adults who have failed conservative strategies such as supervised diet, exercise, and behavior modification programs.

Adjustable gastric band (LAP-BAND / Lap-Band) — FDA indications and age restriction

FDA‑approved indicationsLAP-BAND System approved for surgical treatment of severely obese adults who have failed conservative treatments; originally BMI ≥40 or BMI ≥35 with one or more severe comorbid conditions (or ≥100 lb over ideal weight per 1983 tables).

2011 FDA expansionApproval expanded to include patients with BMI ≥40 kg/m² or patients with BMI ≥30 kg/m² with one or more additional obesity-related comorbid conditions (e.g., diabetes, hypertension).

Requirement prior to useIndicated only in patients who have failed more conservative weight-reduction alternatives such as supervised diet, exercise, and behavior modification programs.

Age contraindicationAdjustable gastric bands are contraindicated in patients younger than 18 years of age.

OpenPayer

Bariatric Surgery (for Kansas Only)

Coverage Criteria

Coding and Billing

Provider Actions and Authorization

Background

Definitions

Revision History