Prior authorization request form Form

Bariatric Surgery
Proprietary information of EmblemHealth. © 2026 EmblemHealth & Affiliates POLICY NUMBER LAST REVIEW MG.MM.SU.18tv2 July 11, 2025

Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the member meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request preauthorization or post-payment review. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. This clinical policy is not intended to pre-empt the judgment of the reviewing medical director or dictate to health care providers how to practice medicine. Health care providers are expected to exercise their medical judgment in rendering appropriate care. Health care providers are expected to exercise their medical judgment in rendering appropriate care.
EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary.
If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. Identification of selected brand names of devices, tests and procedures in a medical coverage policy is for reference only and is not an endorsement of any one device, test or procedure over another. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication.
EmblemHealth may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. EmblemHealth Services Company, LLC, has adopted this policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC, and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Definitions

1. Bariatric surgical procedure types — restrictive, malabsorptive and combined, all of which may be performed using either the laparoscopic or open approach. a. Restrictive — the basic philosophy of restrictive procedures is to create a small gastric reservoir that forces the patient to eat less at any one time. This objective is achieved by reducing the size of the stomach pouch to 30 mL or less and leaving only a small channel to the remaining stomach. b. Malabsorptive — the goal of purely malabsorptive procedures is to bypass a major portion of the absorptive surface of the small intestine for the achievement of rapid, sustained weight loss without a necessary change in eating habits. Purely malabsorptive procedures (without a restrictive component) are not recommended because of the potential for complications, including liver failure and electrolyte depletion. c. Combined restrictive and malabsorptive (hybrid techniques) — the basic philosophy of combined restrictive and malabsorptive procedures is to balance the benefits and risks of the two approaches.

Proprietary information of EmblemHealth/ConnectiCare, Inc. © 2026 EmblemHealth & Affiliates

Page 2 of 10

2. Body Mass Index (BMI) — a quantitative method of defining obesity in a ratio of weight to height (kg/m²).
3. Classification Adults (≥ 18 years of age) BMI Overweight 25–29.9 kg/m² Obese (class I) 30–34.9 kg/m² Severe obesity (class II)
   35–39.9 kg/m² Clinically severe (also referred to as extreme or morbid) obesity (class III)
   40–49.9 kg/m² Super obesity 50–59.9 kg/m² Super-super obesity 60+ kg/m² Children/adolescents (< 18 years of age) BMI
   Class II obesity ≥120% to <140% of the 95th percentile or a BMI ≥ 35 kg/m2 to <39 kg/m2, whichever is lower based on age and sex Class III obesity ≥140% of the 95th percentile or BMI ≥ 40kg/m2, whichever is lower based on age and sex
4. Biliopancreatic Diversion with duodenal switch (BPD/DS) — a combined malabsorptive / restrictive procedure whereby a suprapapillary Roux-en-Y duodeno-jejunostomy is performed in combination with a 70%–80% greater curvature gastrectomy (sleeve resection of the stomach; continuity of the gastric lesser curve is maintained while simultaneously reducing stomach volume). A long-limb Roux-en-Y is then created. The efferent limb acts to decrease overall caloric absorption and the long biliopancreatic limb, diverting bile from the alimentary contents, is intended specifically to induce fat malabsorption.
5. Laparoscopic adjustable gastric banding (LAGB) — a gastric-restrictive implant device used as an alternative to a gastric-restrictive surgery procedure to treat morbid obesity. The system consists of a band of silicone elastomer with an inflatable inner shell and a buckle closure connected by tubing to an access port placed outside the abdominal cavity. The inner diameter of the band can be readily adjusted by the addition or removal of saline through the access port. The band is placed laparoscopically around the upper stomach, 1 cm below the esophagogastric junction. (Must be FDA-approved for Plan consideration) (Not covered for members < 18 years of age)
6. Roux-en-Y gastric bypass (RYGB) — a large portion (approximately 90%) of the stomach is excluded. A gastric pouch is created and anastomosed to the proximal jejunum, causing weight reduction due to a reduction of food intake and mild malabsorption.
7. Single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) — a simplification of the duodenal switch (DS) in which the alimentary limb is eliminated, and the common channel is lengthened. The sleeve is created first, and the duodenum is divided about 4 cm from the pylorus. A single anastomosis is then created between the side of the first or second part of the duodenum and the distal jejunum/proximal ileum, creating an afferent limb of biliopancreatic fluid and an efferent limb that acts like a common channel.

Proprietary information of EmblemHealth/ConnectiCare, Inc. © 2026 EmblemHealth & Affiliates

Page 3 of 10

8. Sleeve gastrectomy — a new procedure that is becoming increasingly popular. In this operation, a tubular stomach is created along the lesser curvature by excising the greater curvature. Approximately an 80– 90% gastrectomy is performed. This is a restrictive procedure and absorption remains normal.
9. Vertical gastric banding (VGB) / vertical-banded gastroplasty (VBG) (vertical gastric stapling or partitioning) — A vertical row of staples and a horizontally placed reinforcing band are positioned across the stomach, creating a proximal pouch and narrowed food outlet. Patients become full post ingestion of only small food amounts.
10. The Obesity Surgery Mortality Risk Score (OS-MRS) — a risk stratification tool that physicians should utilize when determining candidacy of the BMI ≥ 50 kg/m2 member. The OS-MRS assigns 1 point to each of 5 preoperative variables: Age, hypertension, male gender, known risk factors for pulmonary embolism (i.e., previous thromboembolism, preoperative vena cava filter, hypoventilation, pulmonary hypertension) and BMI.

11. Obesity Surgery Mortality Risk Score
    Risk factor Points Age > 45 years 1 Hypertension 1 Male sex 1 Risk factors for pulmonary embolism
    1 Body mass index ≥ 50 kg per m2
    1

    Total:_ Risk group (score) Postoperative mortality risk (deaths/total number of patients who underwent bariatric surgery) Low (0 or 1 points) 5/2164 (0.2%) Moderate (2 or 3 points) 25/2142 (1.2%) High (4 or 5 points) 3/125 (2.4%)

    Guideline Bariatric surgery is considered medically necessary when criteria A or B is met. A. < 18 years of age utilizing any of the above procedures (except adjustable gastric banding) when either of the following criteria are met:

12. Class II obesity, BMI ≥ 35 kg/m2 or 120% of the 95th percentile for age and sex, whichever is lower

    • Clinically significant disease, examples include but are not limited to type 2 diabetes mellitus (T2DM), Idiopathic intracranial hypertension (IIH), and nonalcoholic steatohepatitis (NASH), Blount disease, (slipped capital femoral epiphysis (SCFE), Gastroesophageal reflux disease (GERD), obstructive sleep apnea (OSA) (apnea-hypopnea index [AHI] >5), cardiovascular disease risks (hypertension [HTN], hyperlipidemia, insulin resistance), depressed health-related quality of life

Proprietary information of EmblemHealth/ConnectiCare, Inc. © 2026 EmblemHealth & Affiliates

Page 4 of 10

2. Class III obesity, BMI ≥ 40 kg/m2 or 140% of the 95th percentile for age and sex, whichever is lower (comorbidities not required, but commonly present) B. ≥ 18 years of age utilizing any of the above procedures (in conjunction with cholecystectomy if such is requested) when all of the following criteria are met:
3. Full growth achieved.
4. Absence of specific obesity etiology (i.e., endocrine disorders, e.g., adrenal or thyroid conditions, or treatment of metabolic cause provided, as applicable [does not pertain to diabetes]).
5. Psychological clearance by a mental health professional. If the member has received any behavioral health issue intervention (i.e., counseling or drug therapy) within the past 12 months, then the mental health provider should indicate that the issue of surgery has been discussed with the member and that there are no identified contraindications to the proposed surgery.
   In addition, the member should have no history of substance abuse, or if there is a positive history, the documentation should indicate that the member has been substance abuse free for > 1 year or that he/she is in a controlled treatment program and is stabilized.
   Other contraindications include active eating disorders, active substance abuse and untreated psychiatric illness such as suicidal ideation, borderline personality disorder, schizophrenia, terminal illness and uncontrolled depression. AND

6. BMI ≥ 40 kg/m2 (or BMI ≥ 37.5 kg/m2 in members of Asian descent) or BMI 35–39.9 kg/m² with ≥ 1 significant comorbidity. Accompanying documentation of the following associated comorbid conditions and associated problems must be submitted; any of the following are applicable: a. Daily functional interference to the extent that performance is extensively curtailed.1
   b. Documented circulatory insufficiency. c. Documented physical trauma secondary to obesity complications, which causes the member to be incapacitated. d. Documented respiratory insufficiency. e. Documented primary disease complication, as applicable:
   i. Coronary heart disease and other atherosclerotic diseases.
   ii. Hypertension. iii. Idiopathic intracranial hypertension (pseudotumor cerebri) iv. Osteoarthritis. v. Obstructive sleep apnea. vi. Insulin resistance or type 2 diabetes. vii. Evidence of Nonalcoholic Fatty Liver Disease (NAFLD)

   1 The member must be unable to participate in employment and/or normal activities as a result of the clinically severe obese condition, which could be resolved by weight reduction (e.g., treatable joint disease).

Proprietary information of EmblemHealth/ConnectiCare, Inc. © 2026 EmblemHealth & Affiliates

Page 5 of 10 Gastric Band Adjustments Appropriate as follows:

1. Reduction of band volume: Complaints of difficulty swallowing, persistent reflux or heartburn, nighttime coughing or regurgitation.
   Reduction of band volume may also be appropriate in the setting of maladaptive eating habits such as eating only soft, carbohydrate and fat laden food due to inability to tolerate any solid foods. These complaints, however, should be taken in context with member’s compliance with dietary follow up and recommendations.
2. Increase in band volume: Increased hunger, increased portion sizes. Adjustments would be expected at approximately 6-week intervals until appropriate fill volume has been achieved (member is experiencing early and prolonged satiety with small meal sizes, satisfactory weight loss).
   Adjustments should be performed in the outpatient setting and without fluoroscopic guidance unless the port is not palpable, there is difficulty accessing the port, or leakage is suspected. Surgical Revision Members are eligible for coverage of a surgical revision of a previous gastric restrictive surgery if it is medically necessary as a result of a complication of the original procedure; i.e.:
3. Staple disruption.
4. Obstruction or chronic stricture.
5. Severe esophagitis.
6. Dilatation of the gastric pouch in a member who experienced appropriate weight loss prior to the dilatation. Note: Laparoscopic adjustable banding revisional surgery will be covered for band slippage or erosion, both of which are deemed urgent medical conditions. Surgical Repetition Members are eligible for coverage of repeat bariatric surgery if both of the following criteria are met:
7. Insufficient weight loss (success defined as a weight loss of > 50% of excess body weight)
8. The medically necessary criteria (as outlined above) are met.
   Note: Member compliance with prescribed post-procedure nutrition and exercise program is prerequisite to consideration. Postsurgical Panniculectomy Requests
   (See Cosmetic and Reconstructive Surgery Procedures and/or Abdominoplasty/Panniculectomy) Limitations and Exclusions
9. Surgical revision is not considered medically necessary for members who have a functional operation (without any evidence of medical abnormality) because of inadequate weight loss
10. Cholecystectomies performed incidental to bariatric surgery will only be covered if the bariatric surgery has been authorized/approved

Proprietary information of EmblemHealth/ConnectiCare, Inc. © 2026 EmblemHealth & Affiliates

Page 6 of 10

3. Repair of an asymptomatic or incidentally identified hiatal hernia (CPT codes 43280, 43281, 43282, 43289, 43499 or 43659) will be denied as incidental/inclusive procedures when reported with bariatric surgery code ranges 43770–43775 and 43842–43848, 43644, 43645, 43886, 43887 or 43888). Modifier 59 will not override these codes as hiatal hernia repair is considered an integral part of obesity surgery
4. Case-by-case consideration for preoperative esophagogastroduodenoscopy (EGD) (CPT 43235) will be given for members symptomatic of gastroesophageal reflux disease (GERD) (e.g., heartburn, regurgitation, dysphagia, etc.)
5. Transoral outlet reduction (TORe) (e.g., the Overstitch™ endoscopic suturing system, CPT 43659 or 43999), a minimally invasive revision procedure performed in patients with weight regain or inadequate weight loss following Roux-en-Y gastric bypass, is considered investigational due to insufficient evidence of therapeutic value
6. Adjustable gastric banding is considered investigational for members <18 years of age
7. All other gastric bypass/restrictive procedures (and other treatment modalities not listed above as medically necessary) are considered investigational due to insufficient evidence of therapeutic value. These include, but are not limited to, minimally invasive endoluminal gastric restrictive surgical techniques (e.g., EndoGastric StomaphyX™ endoluminal fastener and delivery system; laparoscopic gastric plication [laparoscopic greater curvature plication [LGCP] with or without gastric banding; balloon- type systems (e.g., Obalon ® Balloon System, ReShape® Integrated Dual Balloon System [CPT 0813T covered Medicare only; 43290, 43291, covered Medicaid and Medicare only]), and vagus nerve-blocking devices (e.g., MAESTRO® Rechargeable System) Procedure Codes
   0813T Esophagogastroduodenoscopy, flexible, transoral, with volume adjustment of intragastric bariatric balloon (eff. 1/1/2024) (Medicare only) 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 43659 Unlisted laparoscopy procedure, stomach 43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, 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 43773 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only 43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components 43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy)

Proprietary information of EmblemHealth/ConnectiCare, Inc. © 2026 EmblemHealth & Affiliates

Page 7 of 10 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 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 43847 Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption 43848 Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) 43860 Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy 43865 Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy 43886 Gastric restrictive procedure, open; revision of subcutaneous port component only 43887 Gastric restrictive procedure, open; removal of subcutaneous port component only 43888 Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only 43999 Unlisted procedure, stomach 47562 Laparoscopy, surgical; cholecystectomy 47600 Cholecystectomy S2083 Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline (Commercial and Medicaid only) Applicable ICD-10 Diagnosis Codes 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

Proprietary information of EmblemHealth/ConnectiCare, Inc. © 2026 EmblemHealth & Affiliates

Page 8 of 10 Z68.54 Body mass index [BMI] pediatric, greater than or equal to 95th percentile for age [BMI of 40 or greater for adolescents who have completed bone growth] Z98.84 Bariatric surgery status References American Academy of Pediatrics. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. 2023. https://publications.aap.org/pediatrics/article/151/2/e2022060640/190443/Clinical-Practice-Guideline-for-the- Evaluation-and. Accessed July 15, 2025. American College of Cardiology/American Heart Association Task Force. Guideline for the Management of Overweight and Obesity in Adults. 2013. https://www.jacc.org/doi/full/10.1016/j.jacc.2013.11.004. Accessed July 15, 2025. American Society of Metabolic and Bariatric Surgery. Updated Position Statement on Sleeve Gastrectomy as a Bariatric Procedure. 2017: https://asmbs.org/app/uploads/2017/11/ASMBS-updated-position-statement-on-sleeve-gastrectomy.-SOARD-Oct-2017- 1.pdf. Accessed July 15, 2025. Curr Pharm Des. 2011;17(12):1209-17. Bariatric surgery: indications, safety and efficacy. Ben-David K1, Rossidis G. DeMaria EJ, Portenier D, Wolfe L. Obesity surgery mortality risk score: proposal for a clinically useful score to predict mortality risk in patients undergoing gastric bypass. Surg Obes Relat Dis. 2007 Mar-Apr;3(2):134-40. National Heart, Lung, and Blood Institute. Managing Overweight and Obesity in Adults. Systematic Evidence Review From the Obesity Expert Panel, 2013. http://www.nhlbi.nih.gov/sites/www.nhlbi.nih.gov/files/obesity-evidence-review.pdf. Accessed July 15,

2025. New York Health Plan Association. Obesity Surgery Workgroup. Surgical Management of Obesity Consensus Guideline. 2004: https://ag.ny.gov/sites/default/files/press-releases/archived/nov28a_04_attach1.pdf. Accessed July 15, 2025. Scand J Surg. 2015 Mar;104(1):18-23. doi: 10.1177/1457496914552344. Epub 2014 Sep 30. Changing trends in bariatric surgery. Lo Menzo E1, Szomstein S1, Rosenthal RJ2. Snow V, Barry P, Fitterman N, Qaseem A, Weiss K, for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Pharmacological and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2005;142:525-531.
      Technology Evaluation Center. Newer techniques in bariatric surgery for morbid obesity. Assessment Program. 2003;18(10):1-52. Technology Evaluation Center. Special report: the relationship between weight loss and changes in morbidity following bariatric surgery for morbid obesity. Assessment Program. 2003;18(9):1-26. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Guidelines for the Clinical Application of Laparoscopic Bariatric Surgery. 2008: http://www.sages.org/publications/guidelines/guidelines-for-clinical-application-of-laparoscopic-bariatric- surgery/. Accessed July 15, 2025. Kim JJ, Rogers AM, Ballem N, Schirmer B. ASMBS updated position statement on insurance mandated preoperative weight loss requirements. Surgery for Obesity and Related Diseases. 2016;12(5):955-959. doi:10.1016/j.soard.2016.04.019. Aminian A, Chang J, Brethauer SA, Kim JJ; American Society for Metabolic and Bariatric Surgery Clinical Issues Committee. ASMBS updated position statement on bariatric surgery in class I obesity (BMI 30-35 kg/m(2)). Surg Obes Relat Dis. 2018 Aug;14(8):1071-
2026. doi:10.1016/j.soard.2018.05.025. Epub 2018 Jun 9. Review. PubMed PMID: 30061070. ASGE Standards of Practice Committee (2015). The role of endoscopy in the bariatric surgery patient. Surgery for Obesity and Related Diseases, 11(3), 507-517. https://doi.org/10.1016/j.soard.2015.02.015. Accessed July 15, 2025. Hayes inc. Evolving Evidence Review. OverStitch Endoscopic Suturing System (Apollo Endosurgery Inc.) for Transoral Outlet Reduction. Lansdale, PA: Hayes Inc.; July 2022, amended July 2023. Specialty matched clinical peer review. American Academy of Pediatrics. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. 2023. https://publications.aap.org/pediatrics/article/151/2/e2022060640/190443/Clinical-Practice-Guideline-for-the- Evaluation-and. Accessed July 15, 2025.

Proprietary information of EmblemHealth/ConnectiCare, Inc. © 2026 EmblemHealth & Affiliates

Page 9 of 10 American College of Cardiology/American Heart Association Task Force. Guideline for the Management of Overweight and Obesity in Adults. 2013. https://www.jacc.org/doi/full/10.1016/j.jacc.2013.11.004. Accessed July 15, 2025. American Society of Metabolic and Bariatric Surgery. Updated Position Statement on Sleeve Gastrectomy as a Bariatric Procedure. 2017: https://asmbs.org/for-healthcare-professionals/. Accessed July 20, 2023. Curr Pharm Des. 2011;17(12):1209-17. Bariatric surgery: indications, safety and efficacy. Ben-David K1, Rossidis G. DeMaria EJ, Portenier D, Wolfe L. Obesity surgery mortality risk score: proposal for a clinically useful score to predict mortality risk in patients undergoing gastric bypass. Surg Obes Relat Dis. 2007 Mar-Apr;3(2):134-40. National Heart, Lung, and Blood Institute. Managing Overweight and Obesity in Adults. Systematic Evidence Review From the Obesity Expert Panel, 2013. http://www.nhlbi.nih.gov/sites/www.nhlbi.nih.gov/files/obesity-evidence-review.pdf. Accessed July 15,

2025. Scand J Surg. 2015 Mar;104(1):18-23. doi: 10.1177/1457496914552344. Epub 2014 Sep 30. Changing trends in bariatric surgery. Lo Menzo E1, Szomstein S1, Rosenthal RJ2. Snow V, Barry P, Fitterman N, Qaseem A, Weiss K, for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Pharmacological and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2005;142:525-531.
      Technology Evaluation Center. Newer techniques in bariatric surgery for morbid obesity. Assessment Program. 2003;18(10):1-52. Technology Evaluation Center. Special report: the relationship between weight loss and changes in morbidity following bariatric surgery for morbid obesity. Assessment Program. 2003;18(9):1-26. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Guidelines for the Clinical Application of Laparoscopic Bariatric Surgery. 2008: http://www.sages.org/publications/guidelines/guidelines-for-clinical-application-of-laparoscopic-bariatric- surgery/. Accessed July 15, 2025. Kim JJ, Rogers AM, Ballem N, Schirmer B. ASMBS updated position statement on insurance mandated preoperative weight loss requirements. Surgery for Obesity and Related Diseases. 2016;12(5):955-959. doi:10.1016/j.soard.2016.04.019. Aminian A, Chang J, Brethauer SA, Kim JJ; American Society for Metabolic and Bariatric Surgery Clinical Issues Committee. ASMBS updated position statement on bariatric surgery in class I obesity (BMI 30-35 kg/m(2)). Surg Obes Relat Dis. 2018 Aug;14(8):1071-
2026. doi:10.1016/j.soard.2018.05.025. Epub 2018 Jun 9. Review. PubMed PMID: 30061070. ASGE Standards of Practice Committee (2015). The role of endoscopy in the bariatric surgery patient. Surgery for Obesity and Related Diseases, 11(3), 507-517. https://doi.org/10.1016/j.soard.2015.02.015. Accessed July 15, 2025. Hayes inc. Evolving Evidence Review. OverStitch Endoscopic Suturing System (Apollo Endosurgery Inc.) for Transoral Outlet Reduction. Lansdale, PA: Hayes Inc.; July 2022, amended July 2023. Specialty matched clinical peer review. Revision History Company(ies) DATE REVISION Emblemhealth Mar. 13, 2026 Added Medicare coverage of endoscopically performed intragastric balloon adjustment EmblemHealth Sept. 12, 2025 Added coverage for members of Asian descent with a BMI of ≥ 37.5 kg/m2
      Added idiopathic intracranial hypertension (pseudotumor cerebri) and evidence of nonalcoholic fatty liver disease (NAFLD) to primary disease complication list EmblemHealth Jul. 11, 2025 Transferred policy content to individual company branded template EmblemHealth ConnectiCare Jul. 14, 2023 Added SADI-S as covered procedure

Proprietary information of EmblemHealth/ConnectiCare, Inc. © 2026 EmblemHealth & Affiliates

Page 10 of 10 EmblemHealth ConnectiCare Jun. 16, 2023 Clarified that CPT codes 43290 and 42391 are covered for Medicaid and Medicare only EmblemHealth ConnectiCare Feb. 10, 2023 Added pediatric criteria EmblemHealth ConnectiCare Aug. 12, 2022 Added Overstitch device as investigational EmblemHealth ConnectiCare Dec. 10, 2021 Added case-by-case consideration language for preoperative esophagogastroduodenoscopy (EGD) for members symptomatic of gastroesophageal reflux disease (GERD) EmblemHealth ConnectiCare Feb. 12, 2021 Removed perquisite for 2 years of insufficient weight loss within Surgical Repetition criteria ConnectiCare Jan. 1, 2020 Retired MCG criteria for this service ConnectiCare has adopted the clinical criteria of its parent corporation EmblemHealth EmblemHealth

Jul. 12, 2019 MCG Panniculectomy cross reference replaced with link to EmblemHealth’s reinstated Abdominoplasty/Panniculectomy guideline, which communicates photo documentation requirement EmblemHealth

Jun. 14, 2019 Modified sub criteria of “documented primary disease complication”: “Medically refractory hypertension” changed to “Hypertension” “Moderate to severe obstructive sleep apnea” changed to “Sleep apnea” EmblemHealth

Jun. 8, 2018 Removed pre-surgical dieting prerequisite and statement that member must not have a life-threatening condition EmblemHealth

Mar. 11, 2016 Clarified devices/techniques, within Limitations/Exclusions Section, which were determined by EmblemHealth to be investigational