CurrentUnitedHealthcarePolicy CSNCT0362.05

Bariatric Surgery (for North Carolina Only)

Policy governing UnitedHealthcare coverage considerations for bariatric surgical procedures for members in North Carolina, referencing North Carolina Medicaid clinical coverage criteria for medical necessity.

Policy Summary

PayerUnitedHealthcare

PolicyBariatric Surgery (for North Carolina Only)

Policy CodePolicy CSNCT0362.05

Change TypeCodes added and coding clarifications

Effective DateApr 1, 2025

Next Review Date

Key ActionFollow North Carolina Medicaid Clinical Coverage Policy 1A-15 for medical necessity when requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

Added CPT codes 0813T and 43999 to the Applicable Codes list.

Notated that CPT codes 0813T, 43290, 43291, 43647, 43648, 43881, and 43882 are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program.

Updated References section to reflect the most current information and archived previous policy version CSNCT0362.04.

2new CPT codes added

7CPT codes flagged as not on NC Medicaid fee schedule

NCjurisdiction governed

1external policy referenced

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Coverage and Medical Necessity Criteria

Medical necessity — governed by NC Medicaid criteria

Refer to North Carolina Medicaid Clinical Coverage Policy 1A-15 for medical necessity criteria; UnitedHealthcare uses that policy for clinical coverage decisions in NC.

Reference: Medical necessity for bariatric surgery is governed by NC Medicaid Clinical Coverage Policy 1A-15 (Surgery for Clinically Severe or Morbid Obesity). Providers must meet the criteria in that policy for coverage determinations.

See referenced policy for specific BMI, comorbidity, and prior-treatment requirements.

Codes in the Applicable Codes list that are marked with an asterisk (*) are not on the State of North Carolina Medicaid Fee Schedule. Because North Carolina Medicaid may not reimburse for those codes, use of an asterisked code (for example, 0813T, 43290, 43291, 43647, 43648, 43881, 43882) could result in denial of coverage or payment by the State of North Carolina Medicaid Program.

This UnitedHealthcare policy does not establish independent clinical medical necessity criteria for bariatric services in North Carolina. Medical necessity determinations for members in North Carolina are made by referencing the North Carolina Medicaid Clinical Coverage Policy 1A-15 (Surgery for Clinically Severe or Morbid Obesity). Services that do not meet the criteria in that North Carolina Medicaid policy will not meet medical necessity under this policy.

Applicable Codes and Coding Guidance

Applicable CPT codes (partial list, laparoscopic and endoscopic procedures)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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Applicable CPT codes (open procedures, revisions, unlisted)CPT

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).
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.
43881	Implantation or replacement of gastric neurostimulator electrodes, antrum, open.
43882	Revision or removal of gastric neurostimulator electrodes, antrum, open.
43886	Gastric restrictive procedure, open; revision of subcutaneous port component only.

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Neurostimulator and nervous system codesCPT

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.

Provider Requirements, Prior Authorization, and Billing Notes

Prior Authorization

Prior Authorization and Medical Necessity

Prior authorization and medical necessity determinations are required. For medical necessity clinical coverage criteria, refer to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Physician: 1A-15, Surgery for Clinically Severe or Morbid Obesity. Providers must obtain prior authorization before performing bariatric procedures or placing device-based adjuncts (e.g., intragastric balloons, gastric neurostimulators). Documentation to support medical necessity should be submitted with the prior authorization request as specified by UnitedHealthcare and may include history of conservative therapy, BMI documentation, comorbidity evidence, and prior treatment records.

Prior authorization required for bariatric surgical procedures and device adjunct placement.
Include documentation of failed conservative weight-loss therapy (supervised diet, exercise, behavioral modification) when applicable.
Submit BMI and comorbidity documentation per NC Medicaid 1A-15 and UnitedHealthcare prior authorization instructions.

Documentation Required

Background

Bariatric care encompasses a range of surgical procedures and device-based interventions, including laparoscopic and open gastric restrictive procedures, gastric bypass with Roux-en-Y reconstruction, adjustable gastric band systems, intragastric balloons, and neurostimulator implantation or revision. The policy lists CPT codes for these procedures (including unlisted procedure codes) for reference; inclusion in the list does not imply coverage. Several device-specific items have FDA indications tied to body mass index and comorbidity criteria, and use of devices such as intragastric balloons is intended as an adjunct to supervised diet and behavior modification programs. This policy was updated to add CPT codes 0813T and 43999 and to note that certain codes are not on the State of North Carolina Medicaid Fee Schedule, which may affect coverage or reimbursement.

Device Definitions and Indications

ORBERA Intragastric Balloon System — indication and adjunct use summary

ORBERA Intragastric Balloon — BMI eligibilityIndicated for adults with BMI ≥30 and ≤40 kg/m2

ORBERA — adjunctive useTo be used as an adjunct to a long‑term supervised diet and behavior modification program

ORBERA — prior treatment requirementIntended for adults who have failed conservative weight reduction strategies (e.g., supervised diet, exercise, behavior modification)

ORBERA — maximum placement durationMaximum placement period is 6 months

Regulatory noteFDA approved (PMA) — informational only; FDA approval alone is not a basis for coverage

LAP‑BAND / Adjustable gastric band — description and BMI thresholds

Policy Changes and Revision History

2025-04-01codes_addedLatest

Added CPT codes 0813T and 43999 to the Applicable Codes list.

2025-04-01fee_schedule_clarification

Noted that CPT codes 0813T, 43290, 43291, 43647, 43648, 43881, and 43882 are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program.