Anthem Blue Cross Connecticut CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity Form



Gastric Bypass and Gastric Restrictive Procedures

Indications

(947661) Is the patient age 18 years or older? 
(947662) Is the recommended surgery one of the following procedures: Biliopancreatic bypass with duodenal switch, Laparoscopic adjustable gastric banding, Roux-en-Y procedure up to 150 cm, Sleeve gastrectomy, or Vertical banded gastroplasty? 
(947663) Does the patient have a body mass index (BMI) of 40 or greater, or BMI of 35 or greater with an obesity-related co-morbid condition such as Diabetes mellitus, Cardiovascular disease, Hypertension, or life-threatening cardio-pulmonary problems? 
(947664) Is there documentation of past participation in a weight loss program? 
(947665) Has there been inadequate weight loss despite a committed attempt at conservative medical therapy? 
(947666) Are pre-operative medical and mental health evaluations and clearances documented? 
(947667) Is there pre-operative education addressing the risks, benefits, realistic expectations and the need for long-term follow-up and adherence to behavioral modifications? 
(947668) Does the treatment plan address the pre- and post-operative needs of the individual undergoing bariatric surgery? 

Contraindications

(947669) Is the surgical repair/correction or reversal being considered without documentation of a surgical complication related to the original surgery? 

Reoperation after Gastric Bypass and Gastric Restrictive Procedures

Notes: Revision/ conversion indications apply to the procedures listed under initial procedure criteria.


Contraindications

(947670) Has the original bariatric surgery resulted in any complications such as fistula, obstruction, erosion, disruption/leakage of suture/staple lines, band herniation, stricture, documented GERD, or pouch enlargement/dilation that requires correction or reversal? 
(947671) For revision/conversion to another surgical procedure, is there inadequate weight loss or weight gain 1 year or longer after the prior procedure, and are the following criteria met: BMI of 40 or greater, or BMI of 35 or greater with a related co-morbid condition; Pre-operative evaluations; Pre-operative education; A treatment plan for the pre- and post-operative periods? 

Initial and Reoperative Bariatric Procedures


Contraindications

(947672) Do the patient's conditions fail to meet the medically necessary criteria listed? 

Bariatric Surgical Procedures for Individuals with a BMI Below 35 kg/m²


Contraindications

(947673) Does the patient have a BMI below 35 kg/m²? 

Not Covered Bariatric Surgical Procedures and Other Treatment Modalities


Contraindications

(947674) Is the requested procedure one of the following: One anastomosis gastric bypass (mini gastric bypass), Malabsorptive procedures excluding biliopancreatic bypass with duodenal switch, Minimally invasive endoluminal techniques (e.g., StomaphyX, endoscopic sleeve gastroplasty), Laparoscopic gastric plication (with or without banding), Balloon systems (Orbera, TransPyloric Shuttle), Vagus nerve blocking devices, Endoscopically placed aspiration tubes (AspireAssist), or Bariatric arterial embolization? 

Further Consideration for Cases Under 18 Years Old

Notes: A bariatric surgeon may request further consideration for cases involving individuals under 18 years old with severe morbid obesity and unique circumstances by contacting a Medical Director. For details, refer to the Rationale section on Bariatric Surgery in Adolescents and Children.


Effective Date

12/28/2023

Last Reviewed

11/09/2023

Original Document

  Reference



This document addresses surgical and other treatments for clinically severe obesity. Clinically severe obesity is a result of persistent and uncontrollable weight gain that constitutes a present or potential threat to life. There are a variety of surgical procedures and other treatment modalities intended for the treatment of clinically severe obesity.

Note: For additional information, please see:

  • CG-MED-59 Upper Gastrointestinal Endoscopy in Adults
  • CG-SURG-92 Paraesophageal Hernia Repair
  • SURG.00007 Vagus Nerve Stimulation

Clinical Indications

Medically Necessary:

Gastric bypass and gastric restrictive procedures are considered medically necessary when all of the following criteria are met:

  1. Individual is age 18 years or older; and
  2. The recommended surgery is one of the following procedures:
    1. Biliopancreatic bypass with duodenal switch
    2. Laparoscopic adjustable gastric banding
    3. Roux-en-Y procedure up to 150 cm
    4. Sleeve gastrectomy
    5. Vertical banded gastroplasty; and
  3. A body mass index (BMI) of 40 or greater, or BMI of 35 or greater with an obesity-related co-morbid condition including, but not limited to:
    1. Diabetes mellitus
    2. Cardiovascular disease
    3. Hypertension
    4. Life threatening cardio-pulmonary problems, (for example, severe obstructive sleep apnea, Pickwickian syndrome, obesity related cardiomyopathy); and
  4. Documentation of all of the following:
    1. Past participation in a weight loss program; and
    2. Inadequate weight loss despite a committed attempt at conservative medical therapy (for example, comprehensive lifestyle interventions, including a combination of diet, exercise, and behavioral modifications); and
    3. Pre-operative medical and mental health evaluations and clearances; and
    4. Pre-operative education which addresses the risks, benefits, realistic expectations and the need for long-term follow-up and adherence to behavioral modifications; and
    5. A treatment plan which addresses the pre- and post-operative needs of an individual undergoing bariatric surgery.

Reoperation

Surgical repair/correction or reversal following gastric bypass and gastric restrictive procedures is considered medically necessary when there is documentation of a surgical complication related to the original surgery, such as a fistula, obstruction, erosion, disruption/leakage of a suture/staple line, band herniation, stricture, documented gastroesophageal reflux disease (GERD) or pouch enlargement/dilation.

Surgical revision/conversion to another surgical procedure* is considered medically necessary when either criteria A or B are met:

  1. For inadequate weight loss or weight gain 1 year or longer after a prior procedure, all the following criteria are met:
    1. BMI of 40 or greater; or
    2. BMI of 35 or greater with an obesity-related co-morbid condition, including but not limited to:
      1. Diabetes mellitus; or
      2. Cardiovascular disease; or
      3. Hypertension; or
      4. Life threatening cardio-pulmonary problems, (for example, severe obstructive sleep apnea, Pickwickian syndrome, obesity related cardiomyopathy);
        and
    3. Pre-operative medical and mental health evaluations and clearances; and
    4. Pre-operative education which addresses the risks, benefits, realistic expectations and the need for long-term follow-up and adherence to behavioral modifications; and
    5. A treatment plan which addresses the pre- and post-operative needs of an individual undergoing bariatric surgery.
  2. There is documentation of a complication related to the initial procedure (including but not limited to, obstruction, stricture or documented GERD).

* Revision/ conversion indications apply to the procedures listed under criteria B for the initial procedure.

Not Medically Necessary:

Initial and reoperative bariatric procedures are considered not medically necessary when the criteria listed above are not met.

Bariatric surgical procedures including, but not limited to, laparoscopic adjustable gastric banding are considered not medically necessary for individuals with a BMI below 35 kg/m².

All other gastric bypass/restrictive procedures and other treatment modalities are considered not medically necessary including, but not limited to the following:

  • One anastomosis gastric bypass, also known as mini gastric bypass;
  • Malabsorptive procedures including, but not limited to, jejunoileal bypass, biliopancreatic bypass without duodenal switch, single anastomosis duodenal switch or very long limb (greater than 150 cm) gastric bypass (other than the biliopancreatic bypass with duodenal switch);
  • Minimally invasive endoluminal gastric restrictive surgical techniques, such as use of the EndoGastric StomaphyX™ endoluminal fastener and delivery system or endoscopic sleeve gastroplasty;
  • Laparoscopic gastric plication (laparoscopic greater curvature plication [LGCP]) with or without gastric banding;
  • Balloon systems, (such as the Orbera Intragastic Balloon System or the TransPyloric Shuttle);
  • Vagus (or vagal) nerve blocking devices;
  • Endoscopically placed percutaneous aspiration tube (such as AspireAssist®);
  • Bariatric arterial embolization.

Further Consideration:

A bariatric surgeon with experience in the pediatric population may request further consideration of a case of an individual under 18 years old with severe morbid obesity and unique circumstances by contacting a Medical Director. For further information, see Rationale section Bariatric Surgery in Adolescents and Children.