MP-01 Bariatric Surgery Form

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Medical Policy

Bariatric Surgery for Adults

Current Effective Date: 6/15/2018
Original Effective Date: 01/12/2015
Next Review/Revision Date: 6/15/2019
Plans: QUEST Integration (Medicaid)

I. Definition

Bariatric surgery is a surgical procedure designed to decrease the utilization of calories by either limiting the ingested volume or the absorptive capacity of the gastrointestinal tract to bring about weight loss.

II. Criteria
The covered surgical procedures include:
▪ Gastric segmentation along its vertical axis with a Rou‐en‐Y bypass with distal anastomosis placed in the jejunum
▪ Laparoscopic adjustable silicone gastric banding
▪ Biliopancreatic Diversion with Duodenal Switch
▪ Laparoscopic longitudinal gastrectomy, such as laparoscopic sleeve gastrectomy
The member who qualifies for the following bariatric surgery procedures must meet ALL of the criteria
1‐8:
A. The member must meet one of the following weight, or weight and comorbidity criteria:

1. Has a Body Mass Index (BMI) > 40kg/m2, or has the weight that is at least 100 pounds over or twice the ideal weight as described in the Metropolitan Life table. Please refer to http://metrolinaweightlosscenter.com/Table1.pdf
2. Has a Body Mass Index (BMI) between 35kg/m2 and 40kg/m2 with one of the following obesity related comorbidities:
   • Type 2 diabetes mellitus  Refractory hypertension
   • Coronary artery disease (CAD) or heart failure (HF) or dyslipidemia
   • Obstructive sleep apnea
   • Gastroesophageal reflux disease (GERD)
   • Pickwickian syndrome
3. Has a Body Mass Index (BMI) between 30kg/m2 and 34.9 kg/m2 with type 2 diabetes.

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Medical Policy
Bariatric Surgery for Adults  For this category of members, only Roux‐en‐Y gastric bypass is covered as the evidence has shown compelling benefit specifically with this particular operation, and not the other procedures.

B. The member is 19 years old or older.

C. The member must be referred by his or her primary care provider to an AlohaCare approved bariatric surgery program.
D. The member has a long history with obesity and has attempted non‐surgical weight loss methods without successful long‐term weight reduction.
E. The member must have completed a consecutive 3‐month or longer medically supervised diet and exercise program.
F. The member does not have untreated medical causes of obesity such as untreated hypothyroidism, Prader‐Willi, and untreated psychiatric condition.
G. A female member must not be pregnant.
H. The member must be compliant with all the pre‐operative and post‐operative visits.
I. The member must be evaluated by a multi‐disciplinary clinical team at a bariatric surgery program that offers comprehensive weight management services. During the bariatric surgery program, the member must be evaluated by a dietician, surgeon, bariatrician, and psychiatrist/psychologist. For a member who has a comorbidity(s), he or she must also be evaluated by the respective specialist(s) for the comorbidity(s), such as, cardiologist, endocrinologist, nephrologist, pulmonologist, oncologist, and rheumatologist. The evaluation process is as follows:

1. Medical evaluation and clearance
   a. Initial consultation
   i. Complete history including: weight, psychosocial, family, dietary, fitness, and past medical history; review of systems and obese related co‐morbid conditions. ii.

   Health risk determination

   b. Consultation from an appropriate consultant based on the member’s history and symptoms including the following systems:
   i. Cardiac
   • Cardiac testing is based on American College of Sports Medicine Risk Criteria

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Medical Policy
Bariatric Surgery for Adults
• Cardiology consult and clearance required for known coronary artery disease
(CAD) or positive stress test results
ii. Pulmonary
• Pulmonary function test (PFTs) obtained on members with known respiratory problems
• No smoking for 3 months
• Pulmonary consult and clearance required for members with known lung disease and BMI ≥ 60, or identified as high risk on PFT results
iii. Sleep  Sleep study based on the member’s history, symptoms, and obstructive sleep apnea screening criteria.
iv. Gastrointestinal
• Helicobacter pylori (H‐pylori) required on all members with a history of peptic ulcer disease and/or severe gastroesophageal reflux disease (GERD)
• Upper gastrointestinal (UGI) examined if the member has severe GERD or hiatal hernia
• Liver ultrasound obtained if the member has repeated elevated transaminases
v. Endocrine
• Euthyroidism
• Diabetic members should demonstrate glucose control (hemoglobin (A1C) ≤
8 and fasting blood sugar (FBS) < 160)
vi. Vascular
• Venous Doppler obtained if the member has a history of deep vein thrombosis (DVT)
• Carotid Doppler or MRI examination obtained if the member has a history of cerebral vascular accident (CVA)

2. Nutrition evaluation by a registered dietitian
   a. Initial consultation includes:
   i. Weight and diet history
   ii. Evaluation of current eating habits, patterns and meal frequency
   iii. Evaluation of current food and beverage choices
   iv. Identification of strengths and weaknesses regarding preparation for surgery (e.g. current exercise habits)

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Bariatric Surgery for Adults
b. Pre‐operative dietary objectives: demonstrates efforts to improve food and beverage choices to increase nutrient quality and prevent negative side effects:
i. The member must complete a consecutive 3‐month or longer medically supervised dietary program.
ii. Understand reasoning and importance of 4‐6 small, frequent meals per day.
iii. Understand importance of protein and why it should be eaten at every meal. iv. Demonstrate ability to track protein and fluid intake accurately.
v. Understand the importance of eliminating carbonated beverages, excessive caffeine, alcohol, high fat and concentrated sugars from diet.
vi. Understand the importance of adequate hydration: be able to verbalize goal of 64 oz of water or non‐carbonated, non‐calorie fluids per day.

3. Mental and behavioral health evaluation
   a. Mental health clearance: Mental health clearance is based on completion of psychological testing, and appropriate treatment and ongoing management of mental health problems and/or eating disorders.
   b. Behavioral health assessment: The purpose of the behavioral health assessment is to identify psychosocial risk factors and make recommendations to both the member and the multidisciplinary Team that are aimed at facilitating the best possible outcome for the member. The pre‐surgical assessment shall address whether the member is adequately prepared from a psychological perspective, to go forward with bariatric surgery and whether there is evidence of any barriers that may interfere with member safety and with adjustment to the surgical procedure.
   c. Surgical evaluation
   i. The member must complete an initial evaluation with the surgeon at which time the member’s medical and surgical history is reviewed. The surgeon will determine if there are any pre‐existing conditions that would preclude the member from being an adequate bariatric surgery candidate.
   ii. The various surgical options will be discussed with the member and the surgeon will recommend the procedure which in his/her opinion is the most appropriate for the member. The nature and purpose of the planned procedure will be explained to the member’s satisfaction.
   iii. The surgeon will explain the potential risks and benefits of the recommended procedure and review the informed consent document with the member.
   iv. The member will be given the informed consent document to take home for further review.

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Bariatric Surgery for Adults
d. Nursing evaluation: The member must attend a pre‐operative class and successfully complete a post‐test. The test is a summation of all members teaching conducted during the evaluation and screening process and is utilized to validate the member’s knowledge, understanding of critical concepts, and readiness for surgery.

III. Guidelines
A. A separate prior authorization (PA) is required for each pre‐operative referral. (Please see criterion
8.)
B. PA is not required for the post‐operative consultation, such as medical nutrition therapy (MNT). MNT is covered up to 3 hours in the first post‐operative calendar year, and up to 1 hour in each 2nd to 5th post‐operative calendar years.
C. A repeat surgery is considered medically necessary only if there is a significant complication that has occurred associated with the original procedure.

IV. Limitations
A. The member who has any one or more of the following conditions is excluded from the coverage of
AlohaCare:
• Unacceptable risk for cardiac complications (MI or stroke within last 6 months).
• Poor myocardial reserve (ejection fraction < 25%)
• Significant obstructive airway disease or respiratory dysfunction (FEV 1 < 1.0 liters)
• End stage renal disease (GFR < 30) without nephrology clearance  End stage liver disease
• Cancer diagnoses within last 5 years without documentation of cure
• Non‐compliance with medical treatment
• Significant psychological disorders (e.g. history of psychosis or mental health disability)  Significant eating disorders
• substance abuse free for ≥12 months
B. The following procedures are considered as experimental and investigational. Therefore, they are not covered:
• Transoral endoscopic surgery
• Mini‐gastric bypass (MGB) or laparoscopic mini‐gastric bypass (LMGBP)  VBLOC® vagal blocking therapy
• Intragastric balloon
• Laparoscopic greater curvature plication, also known as total gastric vertical plication

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Bariatric Surgery for Adults

V. Coding Information
The following medical codes are relevant codes for diagnosis and procedures for bariatric surgery and for informational purposes only. All the medical codes listed in this policy do not constitute or imply benefit coverage or provider reimbursement.

ICD‐10‐CM
Description
Principal/Primary diagnosis codes

E66.01
Morbid obesity
Comorbidities codes

E08 start ICD‐10
Diabetes mellitus due to underlying condition E09
Drug or chemical induced diabetes mellitus E10
Type 1 diabetes mellitus
E11
Type 2 diabetes mellitus
E13
Other specified diabetes mellitus E28.39
Other primary ovarian failure E28.2
Polycystic ovarian syndrome E28.8
Other ovarian dysfunction
E28.9
Ovarian dysfunction, unspecified G93.2
Benign intracranial hypertension I10
Essential (primary) hypertension I11
Hypertensive heart disease I12
Hypertensive chronic kidney disease I13
Hypertensive heart and chronic kidney disease I15
Secondary hypertension
I27.89
Other specified pulmonary heart diseases I50.1
Left ventricular failure
I50.2
Systolic (congestive) heart failure ICD‐10‐CM
Description
I50.3
Diastolic (congestive) heart failure I50.4
Combined systolic (congestive) and diastolic (congestive) heart failure I67.4
Hypertensive encephalopathy I83.011
Varicose veins of right lower extremity with ulcer of thigh

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Bariatric Surgery for Adults
I83.012
Varicose veins of right lower extremity with ulcer of calf I83.013
Varicose veins of right lower extremity with ulcer of ankle I83.014
Varicose veins of right lower extremity with ulcer of heel and midfoot I83.015
Varicose veins of right lower extremity with ulcer other part of foot I83.018
Varicose veins of right lower extremity with ulcer other part of lower leg
I83.021
Varicose veins of left lower extremity with ulcer of thigh I83.022
Varicose veins of left lower extremity with ulcer of calf I83.023
Varicose veins of left lower extremity with ulcer of ankle I83.024
Varicose veins of left lower extremity with ulcer of heel and midfoot I83.025
Varicose veins of left lower extremity with ulcer other part of foot I83.028
Varicose veins of left lower extremity with ulcer other part of lower leg I83.811
Varicose veins of right lower extremities with pain I83.812
Varicose veins of left lower extremities with pain I83.813
Varicose veins of bilateral lower extremities with pain I83.891
Varicose veins of right lower extremities with other complications I83.892
Varicose veins of left lower extremities with other complications I83.893
Varicose veins of bilateral lower extremities with other complications K21.0
Gastro‐esophageal reflux disease with esophagitis K21.9
Gastro‐esophageal reflux disease without esophagitis M16.0
Bilateral primary osteoarthritis of hip M16.11
Unilateral primary osteoarthritis, right hip M16.12
Unilateral primary osteoarthritis, left hip M17.0
Bilateral primary osteoarthritis of knee M17.11
Unilateral primary osteoarthritis, right knee M17.12
Unilateral primary osteoarthritis, left knee M19.071
Primary osteoarthritis, right ankle and foot M19.072
Primary osteoarthritis, left ankle and foot M16.2
Bilateral osteoarthritis resulting from hip dysplasia M16.31
Unilateral osteoarthritis resulting from hip dysplasia, right hip M16.32
Unilateral osteoarthritis resulting from hip dysplasia, left hip M16.4
Bilateral post‐traumatic osteoarthritis of hip M16.51
Unilateral post‐traumatic osteoarthritis, right hip M16.52
Unilateral post‐traumatic osteoarthritis, left hip M16.6
Other bilateral secondary osteoarthritis of hip

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M16.7
Other unilateral secondary osteoarthritis of hip M17.2
Bilateral post‐traumatic osteoarthritis of knee ICD‐10‐CM
Description
M17.31
Unilateral post‐traumatic osteoarthritis, right knee M17.32
Unilateral post‐traumatic osteoarthritis, left knee M17.4
Other bilateral secondary osteoarthritis of knee M17.5
Other unilateral secondary osteoarthritis of knee M19.171
Post‐traumatic osteoarthritis, right ankle and foot M19.172
Post‐traumatic osteoarthritis, left ankle and foot M19.271
Secondary osteoarthritis, left ankle and foot M19.272
Secondary osteoarthritis, left ankle and foot M07.651
Enteropathic arthropathies, right hip M07.652
Enteropathic arthropathies, left hip M12.851
Other specific arthropathies, not elsewhere classified, right hip M12.852
Other specific arthropathies, not elsewhere classified, left hip M07.661
Enteropathic arthropathies, right knee M07.662
Enteropathic arthropathies, left knee M12.861
Other specific arthropathies, not elsewhere classified, right knee M12.862
Other specific arthropathies, not elsewhere classified, left knee M24.151
Other articular cartilage disorders, right hip M24.152
Other articular cartilage disorders, left hip M24.171
Other articular cartilage disorders, right ankle M24.172
Other articular cartilage disorders, left ankle M24.174
Other articular cartilage disorders, right foot M24.175
Other articular cartilage disorders, left foot R26.2
Difficulty in walking, not elsewhere classified M25.151
Fistula, right hip
M25.152
Fistula, left hip
M25.851
Other specified joint disorders, right hip M25.852
Other specified joint disorders, left hip M25.161
Fistula, right knee
M25.162
Fistula, left knee
M25.861
Other specified joint disorders, right knee

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Bariatric Surgery for Adults
M25.862
Other specified joint disorders, left knee M25.171
Fistula, right ankle
M25.172
Fistula, left ankle
M25.174
Fistula, right foot
M25.175
Fistula, left foot
M25.871
Other specified joint disorders, right ankle and foot M25.872
Other specified joint disorders, left ankle and foot M25.18
Fistula, other specified site M51.06
Intervertebral disc disorders with myelopathy, lumbar region M51.86
Other intervertebral disc disorders, lumbar region ICD‐10‐CM
Description
M54.5
Low back pain
M54.31
Sciatica, right side
M54.32
Sciatica, left side
M54.41
Lumbago with sciatica, right side M54.42
Lumbago with sciatica, left side M51.14
Intervertebral disc disorders with radiculopathy, thoracic region M51.15
Intervertebral disc disorders with radiculopathy, thoracolumbar region M51.16
Intervertebral disc disorders with radiculopathy, lumbar region M51.17
Intervertebral disc disorders with radiculopathy, lumbosacral region M53.3
Sacrococcygeal disorders, not elsewhere classified M53.2X8
Spinal instabilities, sacral and sacrococcygeal region M54.03‐M54.09
Panniculitis affecting regions of neck and back, cervicothoracic, thoracic, thoracolumbar, lumbar, lumbosacral, sacral and sacrococcygeal region, multiple sites in spine
M62.830
Muscle spasm of back
M43.21‐M43.28
Fusion of spine, occipito‐atlanto‐axial, cervical, cervicothoracic, thoracic, thoracolumbar, lumbar, lumbosacral, sacral and sacrococcygeal region.
M53.84
Other specified dorsopathies, thoracic region M53.85
Other specified dorsopathies, thoracolumbar region R06.89
Other abnormalities of breathing N39.41
Urge incontinence
N39.3
Stress incontinence (female) (male) N39.46
Mixed incontinence
BMI codes

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Z68.35‐Z68.39
Body Mass Index 35.0‐39.9, adult Z68.41‐V68.45
Body Mass Index 40 and over, adult

CPT
Description
PA Policy 43644
Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux‐en‐Y gastroenterostomy (roux limb 150 cm or less)
PA 43645
Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption
PA 43770
Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device
(eg, gastric band and subcutaneous port components)
PA 43771
Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only
PA 43772
Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only
PA 43773
Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only
PA 43774
Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components
PA 43775
Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) PA 43842
Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical‐banded gastroplasty PA 43843
Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical‐banded gastroplasty
PA 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)
PA 43846
Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less)
Roux‐en‐Y gastroenterostomy
PA 43847
Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption
PA 43886
Gastric restrictive procedure, open; revision of subcutaneous port component only
PA 43887
Gastric restrictive procedure, open; removal of subcutaneous port component only
PA 43888
Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only
PA

References/Resources

Document Name
Effective Date
Source/Link

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Bariatric Surgery versus Intensive Medical Therapy for Diabetes — 5‐ Year Outcomes
2/16/2017
Philip R. Schauer, M.D., et al. http://www.nejm.org/doi/full/10.1056/nejmoa1600869#t= article
Metabolic and Bariatric Surgery
Accreditation and Quality Improvement Program (MBSAQIP) standards manual V2.0
2016
American College of Surgeons American Society for Metabolic and Bariatric Surgery (ACS ASMBS). https://www.facs.org/~/media/files/quality%20programs/b ariatric/mbsaqip%20standardsmanual.ashx
A nationwide safety analysis of bariatric surgery in nonseverely obese patients with type 2 diabetes.
07/2016
Aminian A, Andalib A, Khorgami Z, et al.
http://www.soard.org/article/S1550‐7289(16)30091‐0/pdf
Bariatric Surgery Worldwide 2013
10/2015
Obesity Surgery
https://link.springer.com/article/10.1007/s11695‐0151657‐z
New Procedure Estimates for Bariatric Surgery: What the Numbers Reveal.

05/2014
American Society for Metabolic and Bariatric Surgery (ASMBS) http://connect.asmbs.org/may‐2014‐bariatricsurgery‐growth.html
Roux‐en‐Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia:
The Diabetes Surgery Study randomized clinical trial.
06/2013
Ikramuddin S, Korner J, Lee WJ et al.
JAMA. http://jama.jamanetwork.com/article.aspx?articleid=16938 89
Clinical Practice Guidelines for the
Perioperative Nutritional, Metabolic, and
01/21/2012 Jeffrey I. Mechanick, Adrienne Youdim, Daniel B. Jones, etc. Surgery for Obesity and Related Diseases
Document Name
Effective Date
Source/Link
Nonsurgical Support of the Bariatric Surgery Patient

http://www.soard.org/article/S1550‐7289(13)00022‐ 1/fulltext
Bariatric Surgery
09/10/2012 Alan A Saber, Tarek H El‐Ghazaly. Medscape
http://emedicine.medscape.com/article/197081overview#showall
ACS BSCN Accreditation Program Manual
2011
Version V4.03‐01‐11 http://www.mbsaqip.org/docs/Program%20Manual%20v4 %2004‐10‐12.pdf

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American College of Surgeons Bariatric Surgery Center Network Accreditation Program (ACS BSCN): An Evolution in Quality
10/14/2011 Angela Armijo http://bariatrictimes.com/american‐college‐of‐ surgeonsbariatric‐surgery‐center‐network‐accreditation‐ programacs‐bscn‐an‐evolution‐in‐quality/
Contraindications for Bariatric Surgery
11/29/2010 Dr. Pandula Siribaddana. Sciences360 http://www.sciences360.com/index.php/contraindicationsfor‐ bariatric‐surgery‐7399/
Bariatric Surgery: Risks and Rewards 11/2008
Walter J. Pories. The Endocrine Society
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729256/

Review/Revision History
9/1/2017, updated the criteria, coding information, and references.
6/15/2018, updated the Medical Nutrition Therapy (MNT) coverage for post‐operative members.
6/15/2019, Retired