CurrentUnitedHealthcarePolicy MMP108.10

Surgical Procedures

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This Medicare Advantage medical policy provides coverage-rationale and coding guidance for selected surgical procedures, including bariatric surgery, bronchial thermoplasty, hiatal hernia repair, glaucoma drainage device implantation, and lymphedema surgical treatments. Coverage follows applicable Medicare documents, referenced UnitedHealthcare policies, or InterQual criteria.

Policy Summary

PayerUnitedHealthcare

PolicySurgical Procedures

Policy CodePolicy MMP108.10

Change TypeAdministrative reference update

Effective DateSeptember 1, 2026

Next Review DateN/A

Key ActionFollow the delegate's requirements when utilization management and prior authorization are managed by a delegate.

SourceLink

POLICY UPDATE CHANGES

References to National Government Services were replaced with Wellpoint Federal, and policy version MMP108.09 was archived.

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CurrentUnitedHealthcarePolicy MMP108.10

Surgical Procedures

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Policy Summary

PayerUnitedHealthcare

PolicySurgical Procedures

Policy CodePolicy MMP108.10

Change TypeAdministrative reference update

Effective DateSeptember 1, 2026

Next Review DateN/A

Key ActionFollow the delegate's requirements when utilization management and prior authorization are managed by a delegate.

SourceLink

POLICY UPDATE CHANGES

References to National Government Services were replaced with Wellpoint Federal, and policy version MMP108.09 was archived.

Coverage Criteria by Surgical Procedure

Bariatric Surgery

Apply the applicable Medicare coverage documents first; use the referenced UnitedHealthcare guidance when Medicare criteria are absent or silent.

Bariatric surgery coverage framework: Apply the Medicare National Coverage Determination (NCD) for Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity (100.1) and any applicable Local Coverage Determinations (LCDs) or Local Coverage Articles (LCAs). If no applicable local coverage document exists, or if the NCD or LCD/LCA is silent on the procedure, revision, staged procedure, or surgical approach, refer to the UnitedHealthcare Commercial Medical Policy titled Bariatric Surgery for coverage guidance.

Compliance with applicable LCDs/LCAs is required. The criteria apply to the surgical approach unless the referenced criteria state otherwise.

Bronchial Thermoplasty

Use the referenced UnitedHealthcare Commercial Medical Policy for coverage guidelines.

Bronchial thermoplasty coverage framework: Refer to the UnitedHealthcare Commercial Medical Policy titled Bronchial Thermoplasty for coverage guidelines.

Medicare does not have an NCD for bronchial thermoplasty, and LCDs/LCAs do not exist at this time.

Hiatal Hernia Repair

Use InterQual criteria for coverage guidelines.

Hiatal hernia repair coverage framework: Refer to InterQual CP: Procedures, Antireflux Surgery or Hiatal Hernia Repair for coverage guidelines.

Medicare does not have an NCD for hiatal hernia repair, and LCDs/LCAs do not exist.

Implantation of Glaucoma Drainage Devices

Use the referenced UnitedHealthcare Commercial Medical Policy for coverage guidelines.

Glaucoma drainage device coverage framework: For CPT code 66180, refer to the UnitedHealthcare Commercial Medical Policy titled Glaucoma Surgical Treatments for coverage guidelines.CPT 66180

Medicare does not have an NCD for implantation of glaucoma drainage devices, and LCDs/LCAs do not exist for this service.

Lymphedema Surgical Treatments

Use the referenced UnitedHealthcare Commercial Medical Policy for coverage guidelines.

Lymphedema surgical treatment coverage framework: Refer to the UnitedHealthcare Commercial Medical Policy titled Surgery for the Prevention and Treatment of Lymphedema for coverage guidelines.

Medicare does not have an NCD for lymphedema surgical treatments, and LCDs/LCAs do not exist.

Applicable Procedure Codes

Bariatric SurgeryCPT

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.
43772	Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only.

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Bronchial ThermoplastyCPT

31660	Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe.
31661	Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes.

Hiatal Hernia RepairCPT

43499

Unlisted procedure, esophagus.

Implantation of Glaucoma Drainage DevicesCPT

66180

Aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft.

Lymphedema Surgical TreatmentsCPT

15830	Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy.
15832	Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh.
15833	Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg.
15834	Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip.
15835	Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock.
15836	Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm.
15837	Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand.
15838	Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad.
15839	Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area.
15847	Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure).

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Authorization and Documentation Requirements

Prior Authorization

Follow delegated prior authorization requirements

For UnitedHealthcare Medicare Advantage members whose utilization management and prior authorization requirements are managed by a delegate, follow the delegate’s requirements before providing the service.

Documentation Required

Maintain supporting documentation

Retain or have access to appropriate documentation when requested to support coverage, including medical necessity, documentation requirements, and Medicare coding or billing requirements.

Policy Scope and Context

This UnitedHealthcare Medicare Advantage policy provides coverage-rationale and coding guidance for selected surgical services across bariatric, pulmonary, gastrointestinal, ophthalmic, and lymphatic care. It addresses bariatric surgery, bronchial thermoplasty, hiatal hernia repair, implantation of glaucoma drainage devices, and lymphedema surgical treatments. The medical-necessity criteria referenced in the policy apply regardless of the surgical approach unless otherwise specified.

Coverage is determined through a defined guidance hierarchy. For bariatric surgery, providers must first apply the applicable Medicare National Coverage Determination (NCD) and any relevant Local Coverage Determinations (LCDs) or Local Coverage Articles (LCAs); UnitedHealthcare's Bariatric Surgery policy applies when Medicare guidance is absent or silent. For the other services, the policy directs providers to the applicable UnitedHealthcare commercial policy or, for hiatal hernia repair, InterQual criteria because no applicable Medicare NCD or LCD/LCA is identified. Medicare source materials and the member-specific benefit plan govern when they conflict with this policy.