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Medical Policy Medical and Surgical Management of Obesity including Anorexiants Table of Contents • Policy: Commercial • Description • Information Pertaining to All Policies
• Authorization Information • Policy History • Endnotes • Coding Information • References

Policy Number: 379
BCBSA Reference Number: 7.01.47 (For Plan internal use only) Related Policies
• Gastric Electrical Stimulation, #636 • Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease,

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• Drugs for Weight Loss, #572 • Esophagogastroduodenoscopy (EGD)/Upper Gastrointestinal Endoscopy, #202 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Surgical Management of Obesity Services Preauthorization Request Form Providers, please complete the form. Click here for the Surgical Management of Obesity Services preauthorization request form (#047).

The following bariatric surgeries may be considered MEDICALLY NECESSARY for obesity that has not responded to conservative measures in individuals who meet the “Patient Selection Criteria” described in this policy:

Bariatric Surgery in Adults with Class 3 Obesity (BMI ≥ 40 kg/m2) The following bariatric surgical procedures may be considered MEDICALLY NECESSARY for the treatment of class 3 obesity (BMI ≥ 40 kg/m2) in adults (ages 18 and older) who have failed weight loss by conservative measures:

• Open gastric bypass using a Roux-en-Y
• Laparoscopic gastric bypass using a Roux-en-Y
• Laparoscopic adjustable gastric banding
• Open or laparoscopic sleeve gastrectomy (SG), AND
• Open or laparoscopic biliopancreatic bypass/diversion (ie, Scopinaro procedure) with duodenal switch (DS).

Bariatric Surgery in Adults with Class 2 Obesity (BMI > 35 to 39.9 kg/m2)

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The following bariatric surgery procedures may be considered MEDICALLY NECESSARY for the treatment of class 2 obesity in individuals with at least 1 obesity-related comorbid condition* who have failed weight loss by conservative measures: • Open gastric bypass using a Roux-en-Y, • Laparoscopic gastric bypass using a Roux-en-Y, • Laparoscopic adjustable gastric banding, • Sleeve gastrectomy (SG), and • Open or laparoscopic biliopancreatic bypass/diversion (ie, Scopinaro procedure) with duodenal switch (DS).

*Weight-Related Complications Clinical Practice Guidelines list the following conditions weight-related complications, defined as conditions caused by or exacerbated by excess adiposity:1, • Asthma • Cardiovascular disease • Certain types of cancer (eg, colorectal cancer) • Diabetes mellitus, Type 2 • Dyslipidemia • GERD • Hypertension • Infertility • Male hypogonadism • Mental health (depression) • Metabolic syndrome • Nonalcoholic fatty liver disease (nonalcoholic fatty liver and nonalcoholic steatohepatitis) • Obstructive sleep apnea • Osteoarthritis • Polycystic ovarian syndrome • Prediabetes • Stroke • Urinary stress incontinence

Bariatric surgery should be performed in appropriately selected individuals, by surgeons who are adequately trained and experienced in the specific techniques used, and in institutions that support a comprehensive bariatric surgery program, including long-term monitoring and follow-up postsurgery. (see Policy Guidelines for bariatric surgery selection criteria).

Bariatric Surgery in Individuals with Class 1 Obesity (BMI > 30 to 34.9 kg/m2) and Type 2 Diabetes For individuals with Class 1 obesity (BMI > 30 to 34.9 kg/m2) and type 2 diabetes, the following bariatric surgery procedures may be considered MEDICALLY NECESSARY in adults who have failed weight loss by conservative measures: • Biliopancreatic diversion with DS, • Laparoscopic adjustable gastric banding, • Roux-en-Y gastric bypass, and • Sleeve gastrectomy.

Bariatric surgery is considered INVESTIGATIONAL for individuals with Class 1 obesity who do not have diabetes.

Bariatric surgery is considered INVESTIGATIONAL for individuals with a BMI less than 30 kg/m2.

The following bariatric surgical procedures are considered INVESTIGATIONAL for the treatment of obesity:

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• Vertical-banded gastroplasty • Gastric bypass using a Billroth II procedure (mini-gastric bypass) • Biliopancreatic diversion (BPD) without duodenal switch (DS) • Long limb gastric bypass (ie, >150 cm) • Two-stage bariatric surgery procedures (eg, sleeve gastrectomy as initial procedure followed by BPD at a later time) • Laparoscopic gastric plication • Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SG) (SADI-S) • One anastomosis gastric bypass1 • Jejunoileal bypass1 • Horizontal gastric partitioning1 • Gastric wrapping1 • Gastric Electric Stimulation for the treatment of obesity (Gastric pacemaker).1

Revision Bariatric Surgery Revision surgery to address perioperative or late complications of a bariatric procedure is considered MEDICALLY NECESSARY. These include but are not limited to, staple line failure, obstruction, stricture, nonabsorption resulting in hypoglycemia or malnutrition, weight loss of 20% or more below ideal body weight, and band slippage that cannot be corrected with manipulation or adjustment.

Revision of a primary bariatric procedure that has failed due to dilation of the gastric pouch or dilation proximal to an adjustable gastric band (documented by upper gastrointestinal examination or endoscopy) is considered MEDICALLY NECESSARY if the initial procedure was successful in inducing weight loss prior to pouch dilation, and the individual has been compliant with a prescribed nutrition and exercise program.

Revision surgery to address severe gastroesophageal reflux disease refractory to medical treatment is considered MEDICALLY NECESSARY.

Bariatric Surgery in Adolescents Bariatric surgery in adolescents (ages 12-18, who may not yet have completed bone growth) may be considered MEDICALLY NECESSARY according to similar weight-based criteria used for adults, but greater consideration should be given to psychosocial and informed consent issues. Individuals must meet the “Patient Selection Criteria” described in this policy. In addition, any devices used for bariatric surgery must be in accordance with the FDA-approved indications.

Bariatric Surgery in Preadolescent Children Bariatric surgery is considered INVESTIGATIONAL for the treatment of obesity in preadolescent children.

Concomitant Hiatal Hernia Repair with Bariatric Surgery
Repair of a hiatal hernia at the time of bariatric surgery may be considered MEDICALLY NECESSARY for individuals who have a preoperatively-diagnosed hiatal hernia with indications for surgical repair.

The Society of American Gastrointestinal and Endoscopic Surgeons have issued evidence-based guidelines for the management of hiatal hernia. Recommendations for indications for repair are as follows:
• Repair of a type I hernia [sliding hiatal hernias, where the gastroesophageal junction migrates above the diaphragm] in the absence of reflux disease is not necessary (moderate quality evidence, strong recommendation).
• All symptomatic paraesophageal hiatal hernias should be repaired (high quality evidence, strong recommendation), particularly those with acute obstructive symptoms or which have undergone volvulus.

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• Routine elective repair of completely asymptomatic paraesophageal hernias may not always be indicated. Consideration for surgery should include the patient’s age and comorbidities (moderate quality evidence, weak recommendation).

Repair of a hiatal hernia that is diagnosed at the time of bariatric surgery, or repair of a preoperatively diagnosed hiatal hernia in individuals who do not have indications for surgical repair is considered INVESTIGATIONAL.

Endoscopic Procedures The following endoscopic procedures are considered INVESTIGATIONAL as a primary bariatric procedure or as a revision procedure, (ie, to treat weight gain after bariatric surgery to remedy large gastric stoma or large gastric pouches) including but not limited to: • Aspiration therapy device • Bariatric endoscopic antral myotomy (BEAM)1
• Confirmation of gastric band placement1 • Endoscopic gastric suturing (e.g., with the Apollo1Overstitch™ System) for revision of gastric bypass or as a primary bariatric procedure1
• Endoscopic sleeve gastroplasty • Insertion of the StomaphyX™ device • Intragastric balloons
• Placement of TransPyloric Shuttle device for bariatric indications1 • Pre-evaluation for bariatric surgery unless meeting the requirements in Medical Policy 202
• Sclerotherapy for bariatric indications (e.g., revision of Roux-en-Y procedure to address weight regain) 1
• Single Anastomosis Duodenal-ileal switch (SADI-s)1 AND • Use of an endoscopically placed duodenojejunal sleeve.

POLICY GUIDELINES Bariatric surgery should be performed in appropriately selected individuals, by surgeons who are adequately trained and experienced in the specific techniques used, and in institutions that support a comprehensive bariatric surgery program, including long-term monitoring and follow-up postsurgery.

Bariatric Surgery Selection Criteria
Adults over the age of 18 or who have documented complete bone growth are eligible for obesity surgery if ALL of the following criteria are met:

• The physician has indicated that the patient: o Is a well informed and motivated patient with acceptable operative risks, AND o Has a strong desire for substantial weight loss, AND o Has failed other non-surgical approaches to long-term weight loss. These approaches (ie, diet and exercise plans, behavioral changes, etc.) and duration are up to the surgeon’s discretion, AND o Is enrolled in a program which provides pre-op and post-op multidisciplinary evaluation and care including behavioral health, nutrition, and medical management AND o The patient is morbidly obese with a BMI > 40kg/m². OR • The individual has a BMI >35kg/m² and the physician has indicated that the individual has one or more of the following severe obesity-related complications:
o Obstructive sleep apnea o Obesity-hypoventilation syndrome o Pickwickian syndrome o Nonalcoholic fatty liver disease or nonalcoholic steatohepatitis o Pseudotumor cerebri
o Gastroesophageal reflux disease o Asthma

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o Venous stasis disease o Severe urinary incontinence o Debilitating arthritis or considerably impaired quality of life o Obesity related cardiomyopathy
o At least Stage 1 Hypertension based on JNC-VII (SBP >140 and/or DBP >90) after combination pharmacotherapy
o Coronary artery disease, OR
o Obesity related pulmonary hypertension
OR o The individual has a BMI >30kg/m2 and has type 2 diabetes.

Repeat Surgical Procedures Repeat surgical procedures for revision or conversion to another surgical procedure is considered MEDICALLY NECESSARY for individuals who regained weight after the initial surgery or for inadequate weight loss (unrelated to a surgical complication of a prior procedure).1

Non-procedural Treatments for Obesity The physician-directed visits and testing aspects of multi-faceted dietary programs such as Health Management Resources may be considered MEDICALLY NECESSARY.1

Non-physician directed and food replacement or supplement components of multi-faceted dietary programs such as Health Management Resources are considered NOT MEDICALLY NECESSARY.1

The following medical and pharmaceutical treatments for obesity are considered NOT MEDICALLY NECESSARY:1 • Multi-faceted dietary programs such as Optifast, and Medifast
• Orlistat ™ (Xenical ®) because it may be purchased over the counter (alli ™) without a prescription
• Anorexiants.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is required for surgical services. Prior authorization is not required for medical services. Commercial PPO
Prior authorization is required for surgical services. Prior authorization is not required for medical services.

Requesting Prior Authorization Using Authorization Manager Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.

To ensure the request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources • Refer to our Authorization Manager page for tips, guides, and video demonstrations.

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Complete Prior Authorization Request Form for Surgical Management of Obesity (047) using Authorization Manager.

For out of network providers: Requests should still be faxed to 888-282-0780. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity: CPT Codes CPT codes: Code Description 43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components)
43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy)
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
43848 Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)
ICD-10 Procedure Codes ICD-10-PCS procedure codes: Code Description 0DB64Z3 Excision of Stomach, Percutaneous Endoscopic Approach, Vertical 0D160ZA Bypass Stomach to Jejunum, Open Approach 0D160ZB Bypass Stomach to Ileum, Open Approach 0D164ZA Bypass Stomach to Jejunum, Percutaneous Endoscopic Approach 0D164ZB Bypass Stomach to Ileum, Percutaneous Endoscopic Approach 0D190ZB Bypass Duodenum to Ileum, Open Approach 0D194ZB Bypass Duodenum to Ileum, Percutaneous Endoscopic Approach 0DB60Z3 Excision of Stomach, Open Approach, Vertical 0DB60ZZ Excision of Stomach, Open Approach 0DB80ZZ Excision of Small Intestine, Open Approach 0DB90ZZ Excision of Duodenum, Open Approach 0DBB0ZZ Excision of Ileum, Open Approach 0DM60ZZ Reattachment of Stomach, Open Approach 0DM64ZZ Reattachment of Stomach, Percutaneous Endoscopic Approach

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0DM80ZZ Reattachment of Small Intestine, Open Approach 0DM84ZZ Reattachment of Small Intestine, Percutaneous Endoscopic Approach 0DM90ZZ Reattachment of Duodenum, Open Approach 0DM94ZZ Reattachment of Duodenum, Percutaneous Endoscopic Approach 0DMA0ZZ Reattachment of Jejunum, Open Approach 0DMA4ZZ Reattachment of Jejunum, Percutaneous Endoscopic Approach 0DMB0ZZ Reattachment of Ileum, Open Approach 0DMB4ZZ Reattachment of Ileum, Percutaneous Endoscopic Approach 0DQ60ZZ Repair Stomach, Open Approach 0DQ64ZZ Repair Stomach, Percutaneous Endoscopic Approach 0DQ80ZZ Repair Small Intestine, Open Approach 0DQ84ZZ Repair Small Intestine, Percutaneous Endoscopic Approach 0DQ90ZZ Repair Duodenum, Open Approach 0DQ94ZZ Repair Duodenum, Percutaneous Endoscopic Approach 0DQA0ZZ Repair Jejunum, Open Approach 0DQA4ZZ Repair Jejunum, Percutaneous Endoscopic Approach 0DQB0ZZ Repair Ileum, Open Approach 0DQB4ZZ Repair Ileum, Percutaneous Endoscopic Approach 0DV60CZ Restriction of Stomach with Extraluminal Device, Open Approach 0DV64CZ Restriction of Stomach with Extraluminal Device, Percutaneous Endoscopic Approach

The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT and/or ICD Procedure Codes above if medical necessity criteria are met:

ICD-10 Diagnosis Codes ICD-10-CM Diagnosis codes: Code Description E66.01 Morbid (severe) obesity due to excess calories Z68.35 Body mass index (BMI) 35.0-35.9, adult Z68.36 Body mass index (BMI) 36.0-36.9, adult Z68.37 Body mass index (BMI) 37.0-37.9, adult Z68.38 Body mass index (BMI) 38.0-38.9, adult Z68.39 Body mass index (BMI) 39.0-39.9, adult Z68.41 Body mass index (BMI) 40.0-44.9, adult Z68.42 Body mass index (BMI) 45.0-49.9, adult Z68.43 Body mass index (BMI) 50-59.9 , adult Z68.44 Body mass index (BMI) 60.0-69.9, adult Z68.45 Body mass index (BMI) 70 or greater, adult

The following CPT codes are considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity: CPT Codes CPT codes: Code Description 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)

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43645 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption 43842 Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty 43843 Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty 43847 Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption 43889 Gastric restrictive procedure, transoral, endoscopic sleeve gastroplasty (ESG), including argon plasma coagulation, when performed

The following HCPCS codes are considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: HCPCS Codes HCPCS codes: Code Description C9785 Endoscopic outlet reduction, gastric pouch application, with endoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components

Description Bariatric Surgery Bariatric surgery is performed to treat obesity and obesity-related comorbid conditions. The first treatment of obesity is dietary and lifestyle changes. Although this strategy may be effective in some patients, only a few individuals with obesity can reduce and control weight through diet and exercise. Most patients find it difficult to comply with these lifestyle modifications on a long-term basis. When conservative measures fail, some patients may consider surgical approaches.

Summary Description Bariatric surgery is a treatment for class III obesity in patients who fail to lose weight with conservative measures. There are numerous gastric and intestinal surgical techniques available. While these techniques have heterogeneous mechanisms of action, the result is a smaller gastric pouch that leads to restricted eating. However, these surgeries may lead to malabsorption of nutrients or eventually to metabolic changes.

Summary of Evidence Adults with Class 3 Obesity For individuals who are adults (18 years or older) with class 3 obesity (BMI > 40kg/m2) who are treated with bariatric surgery using open or laparoscopic gastric bypass using a Roux-en-Y, laparoscopic adjustable gastric banding, sleeve gastrectomy, or open or laparoscopic biliopancreatic bypass/diversion (ie, Scopinaro procedure) with duodenal switch, the evidence includes randomized controlled trials (RCTs), observational studies, and systematic reviews. Relevant outcomes are overall survival (OS), change in disease status, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. Evidence from nonrandomized comparative studies, case series, and meta-analyses of RCTs has consistently reported that bariatric surgery results in substantially greater weight loss than nonsurgical therapy. Data from the largest comparative study (the SOS study) found that bariatric surgery was associated with improvements in mortality, T2D, cardiovascular risk factors, and quality of life. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Adults with Class 2 Obesity For individuals who are adults (18 years or older) with class 2 obesity (BMI > 35 to 39.9ckg/m2) who are treated with bariatric surgery using open or laparoscopic gastric bypass using a Roux-en-Y, laparoscopic adjustable gastric banding, sleeve gastrectomy, or open or laparoscopic biliopancreatic bypass/diversion (ie, Scopinaro procedure) with duodenal switch, the evidence includes RCTs, observational studies, and

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systematic reviews. Relevant outcomes are overall survival (OS), change in disease status, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. Evidence from nonrandomized comparative studies, case series, and meta-analyses of RCTs has consistently reported that bariatric surgery results in substantially greater weight loss than nonsurgical therapy. Data from the largest comparative study (the SOS study) found that bariatric surgery was associated with improvements in mortality, T2D, cardiovascular risk factors, and quality of life. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Adults with Class 1 Obesity and Type 2 Diabetes For individuals who have Class 1 obesity (BMI >30 to 34.9 kg/m2) and T2D who receive gastric bypass, SG, BPD, or LAGB, the evidence includes systematic reviews of RCTs and observational studies. Relevant outcomes are OS, change in disease status, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. Systematic reviews of RCTs and observational studies have found that certain types of bariatric surgery are more efficacious than medical therapy as a treatment for T2D in adults with obesity, including those with a BMI between 30 and 34.9 kg/m2. The greatest amount of evidence assesses gastric bypass, with some comparative studies on LAGB, LSG, and BPD. Systematic reviews have found significantly greater remission rates of diabetes, decrease in HbA1c levels, and decrease in BMI with bariatric surgery than with nonsurgical treatment. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Adults with a Body Mass Index <35 kg/m2 Who Do Not Have Type 2 Diabetes For individuals with a BMI <35 kg/m2 who do not have type 2 diabetes who receive bariatric surgery, the evidence includes systematic reviews of RCTs and observational studies. Relevant outcomes are OS, change in disease status, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. A few small RCTs and case series have reported a loss of weight and improvements in comorbidities for this population. However, the evidence does not permit conclusions on the long-term risk-benefit ratio of bariatric surgery in this population. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Revision Bariatric Surgery For individuals who are adults who receive revision bariatric surgery, the evidence includes systematic reviews, case series, and registry data. Relevant outcomes are OS, change in disease status, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. SSystematic reviews and case series have shown that patients receiving revision bariatric surgery experienced satisfactory weight loss and reduced comorbidities including GERD. Data from a multinational bariatric surgery database has found that corrective procedures following primary bariatric surgery are relatively uncommon but generally safe and efficacious. A large retrospective analysis found a serious complication rate of 7.2% for conversion to RYGB in 13,432 individuals and no difference in 30-day mortality compared to primary RYGB. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Adolescents with Obesity For individuals who are adolescent children with obesity who receive gastric bypass, or LAGB, or SG, the evidence includes RCTs, observational studies, and systematic reviews. Relevant outcomes are OS, change in disease status, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. Systematic reviews of studies on bariatric surgery in adolescents, who mainly received gastric bypass or LAGB or SG, found significant weight loss and reductions in comorbidity outcomes with bariatric surgery. For bariatric surgery in the adolescent population, although data are limited on some procedures, studies have generally reported that weight loss and reduction in risk factors for adolescents are similar to that for adults. Most experts and clinical practice guidelines have recommended that bariatric surgery in adolescents be reserved for individuals with severe comorbidities, or for individuals with a BMI greater than 50 kg/m2. Also, greater consideration should be placed on the patient developmental stage, on the psychosocial aspects of obesity and surgery, and on ensuring that the patient can provide fully informed consent. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

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Preadolescent Children with Obesity For individuals who are preadolescent children with obesity who receive bariatric surgery, there are no studies focused solely on this population. Relevant outcomes are OS, change in disease status, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. Several studies of bariatric surgery in adolescents have also included children younger than 12 years old. A recent (2021) cohort study included 801 children ages 5 to 14 years in their total cohort of children and adolescents, and excess weight loss and comorbidity resolution were substantial and long-lasting without safety concerns across all age groups. However, comparative studies are still lacking. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Hiatal Hernia Repair with Bariatric Surgery For individuals with obesity and a preoperative diagnosis of a hiatal hernia who receive hiatal hernia repair with bariatric surgery, the evidence includes a systematic review, cohort studies, and case series. Relevant outcomes are OS, change in disease status, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. A systematic review found that hiatal hernia repair during SG was superior to SG alone for gastroesophageal reflux disease remission, but not de novo. Results from the cohort studies and case series have shown that, when a preoperative diagnosis of a hiatal hernia has been present, repairing the hiatal hernia during bariatric surgery resulted in fewer complications. However, the results are limited to individuals with a preoperative diagnosis. There was no evidence on the use of hiatal hernia repair when the hiatal hernia diagnosis is incidental. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Policy History Date Action 1/2026 Clarified coding information.
10/2025 Policy clarified to include bariatric endoscopic antral myotomy (BEAM) to investigational endoscopic procedures. 10/15/2025. 10/2025 Policy revised to include additional investigational endoscopic procedures. EGD/upper GI endoscopy is addressed in MP #202. Effective 10/1/2025.
9/2024 Annual policy review. Policy updated with literature review through March 7, 2024. References added. Evidence review extensively pruned for clarity.
▪ Policy statements and evidence review indications revised to align with current obesity classification terminology and clinical practice guidelines.
▪ New medically necessary statement added for bariatric surgery in adults with Class 2 obesity and at least 1 obesity-related comorbid condition.
▪ Medically necessary statement on revision surgery clarified to include GERD as an indication for revision surgery.
Effective 9/1/2024. 5/2024 Policy revised to include Bariatric Surgery in Adolescents (ages 12-18, who may not yet have completed bone growth) is considered medically necessary according to similar weight-based criteria used for adults. Bariatric Surgery Selection Criteria clarified to include: The individual has a BMI >30kg/m2 and has type 2 diabetes. One anastomosis gastric bypass added under investigational bariatric surgical procedures for the treatment of class III (BMI >40 kg/m2 or >35 kg/m2 with any of the comorbidities listed) obesity in adults who have failed weight loss by conservative measures. Effective 5/1/2024. 9/2023 Policy clarified to include prior authorization requests using Authorization Manager.
7/2023 Annual policy review. For completeness, medically necessary policy statement added for individuals who are diabetic and do not have class III obesity. Although no new evidence added for this population, evidence was previously determined to be sufficient. Additional minor editorial refinements made to policy statements with intent unchanged. Several guidelines updated and added. Effective 7/1/2023.

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Single Anastomosis Duodenal-ileal switch (SADI-s) and Apollo Device are investigational as a primary bariatric procedure or as a revision procedure. Coding Clarified. Effective 7/1/2023. 1/2023 Clarified coding information. 6/2022 Policy clarified. Policy statements on revision surgery to address perioperative or late complications of a bariatric procedure added.
6/2022 Prior authorization information clarified for PPO plans. Effective 6/1/2022. 4/2021 Annual policy review. Policy statement for adolescent bariatric surgery clarified due to updated weight-based criteria used for adults issued by the American Academy of Pediatrics. 1/2021 Policy clarified to include the following criteria: Has failed other non-surgical approaches to long-term weight loss. These approaches (i.e., diet and exercise plans, behavioral changes, etc.) and duration are up to the surgeon’s discretion. 1/2021 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
4/2020 Annual policy review. Description, summary and references updated. Policy statements unchanged. 4/2019 Annual policy review. Description, summary and references updated. Policy statements unchanged. 3/2018 Annual policy review. New references added.
9/2017 Annual policy review. Investigational statement on endoscopic procedures rewritten for clarity; aspiration therapy device added to the investigational statement. Investigational statement on bariatric surgery in preadolescent children added. Effective 9/1/2017. 7/2016 Annual policy review. Single anastomosis duodenoileal bypass with sleeve gastrectomy added to investigational statement. Effective 7/1/2016. 3/2016 Policy statement removed: Medical management of obesity may be medically necessary including laboratory services and other diagnostic tests prescribed by the physician specialist, and nutritional counseling in accordance with the member’s subscriber certificate. Clarified coding information. Effective 3/1/2016. 1/2016 Prior authorization information clarified. 1/1/2016. 10/2015 Clarified coding information. 6/2015 Medically necessary statements on revision bariatric surgery retired. Coding information clarified. Effective 6/1/2015. 3/2015 Annual policy review. New medically necessary and investigational indications described. Statement on bariatric surgery in individuals with BMI <35 changed from investigational to not medically necessary. Effective 3/1/2015. 10/2014 Language on Health Management Resources clarified. 9/2014 Clarified coding information. Surgical Management of Obesity Services Preauthorization Request Form transferred to #047. 6/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/2015. 3/2014 Annual policy review. Language added to policy statement on revision surgery to include complications of laparoscopic adjustable gastric banding. Effective 3/1/2014. 4/2013 Annual policy review. Changes to policy statement. Effective 4/1/2013. 11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements.
1/2012 Annual policy review. Changes to policy statements. 5/2011 Reviewed - Medical Policy Group - Pediatrics and Endocrinology. No changes to policy statements. 11/2010 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. No changes to policy statements. 11/2010 Annual policy review. Changes to policy statements. 2/2010 Reviewed - Medical Policy Group - Psychiatry and Ophthalmology. No changes to policy statements.

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11/2009 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. No changes to policy statements. 11/2009 Annual policy review. Changes to policy statements. 2/2009 Reviewed - Medical Policy Group - Psychiatry and Ophthalmology. No changes to policy statements. 11/2008 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. No changes to policy statements. 9/2008 Annual policy review. Changes to policy statements. 4/2008 Annual policy review. Changes to policy statements. 2/2008 Reviewed - Medical Policy Group - Psychiatry and Ophthalmology. No changes to policy statements. 5/2007 Annual policy review. BCBSA National medical policy review. Changes to policy statements. 2/2007 Reviewed - Medical Policy Group - Psychiatry and Ophthalmology. No changes to policy statements. 5/1996 New policy describing covered and non-covered indications. Effective 5/1996.

Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

1. Garvey WT, Mechanick JI, Brett Em, ET Al. American Association Of Clinical Endocrinologists and American College Of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity. Executive Summary complete Guidelines Available At https://www.aace.com/publications/guidelines. Endocr Pract. Jul 2016; 22(7): 842-84. PMID 27472012
2. Centers for Disease Control and Prevention. Overweight & Obesity. Last Reviewed: June 3, 2022; https://www.cdc.gov/obesity/basics/adult-defining.html. Accessed March 29, 2024.
3. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. Oct 13 2004;292(14):1724-1737. PMID 15479938
4. Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. Apr 5 2005;142(7):547-559. PMID 15809466
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     1 Based on expert opinion