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

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.