Bariatric Surgery Form

1 Bariatric Surgery - Medical Policy Updated Revision Effective: April 1, 2026
Policy Number: UM061POL Approval Date: Line(s) of Business: Commercial
Medicare Advantage
Medicaid (BeHealthy) Description Bariatric surgical procedures affect weight loss through three fundamental mechanisms, i.e., malabsorption, restriction, and the neurohormonal response that regulates hunger and energy balance. Some procedures have both a restrictive and malabsorptive component. Restrictive procedures limit caloric intake by reducing the stomach's reservoir capacity via resection, bypass, or creation of a proximal gastric outlet. The sleeve gastrectomy has become the main restrictive procedure, but it is probably more successful due to its hormonal effects on hunger control. Malabsorptive procedures decrease the effectiveness of nutrient absorption by shortening the absorption length of the functional small intestine, either through bypass of the small bowel absorptive surface area or diversion of the biliopancreatic secretions that facilitate absorption. Jejunoileal bypass (JIB) and the biliopancreatic diversion (BPD) are examples of malabsorptive procedures. Profound weight loss can be achieved by a malabsorptive operation, depending upon the effective length of the functional small bowel segment. However, the benefit of superior weight loss can be offset by significant metabolic complications, such as protein calorie malnutrition and various micronutrient deficiencies. Restrictive and malabsorptive procedures include the Roux-en-Y gastric bypass (RYGB), the BPD with duodenal switch (BPD/DS), and the single-anastomosis duodenal ileal bypass with sleeve gastrectomy (SADI-S). In the RYGB, a small gastric pouch limits oral intake. However, the small bowel reconfiguration provides additional mechanisms favoring weight loss, including dumping physiology, positive hormonal changes, and mild malabsorption. There is an effect on hunger as well, likely due to the hormonal changes. The one-anastomosis gastric bypass (OAGB) also works by restriction and malabsorption as well as hormonal modulation. 12/29/2025

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 Line of Business

Commercial:
• HNE has adopted InterQual* criteria for the following procedures: o CP: Procedures Bariatric or Metabolic Surgery o CP: Procedures Bariatric or Metabolic Surgery (Adolescent)

Medicaid – BeHealthy:
Health New England follows MassHealth Medical necessity guidelines for Bariatric surgery:
https://www.mass.gov/guides/masshealth-guidelines-for-medical-necessity-determination-for-bariatric-surgery

Medicare:
Health New England follows Local Coverage Determination (NCD) 100.1 Bariatric Surgery for Treatment of Co- morbid Conditions Related to Morbid Obesity. https://www.cms.gov/medicare-coverage-database/search.aspx

Policy

I. Initial Bariatric Surgery and Repeat Bariatric Surgery
A. Health New England has adopted the following policies for commercial line of business a. CP: Procedures Bariatric or Metabolic Surgery b. CP: Procedures Bariatric or Metabolic Surgery (Adolescent) B. Health New England has adopted the following policies for Medicaid line of business a. https://www.mass.gov/doc/guidelines-for-medical-necessity-determination-for- bariatric-surgery/download C. Health New England had adopted the following policies for Medicare line of business a. NCD 100.1 Bariatric Surgery for Treatment of Co-morbid Conditions Related to Morbid Obesity.

                                       https://www.cms.gov/medicare-coverage-database/search.aspx

II. Any bariatric procedure not listed as covered is considered experimental and investigational, including but not limited to:

• Fobi-Pouch (limiting proximal gastric pouch)
• Gastroplasty (stomach stapling)
• Intestinal bypass (jejunoileal bypass)
• Intragastric balloon (e.g., Orbera Intragastric Balloon System, ReShape Integrated Dual BalloonSystem)
• Loop gastric bypass
• Mini-gastric bypass
• Natural Orifice Transluminal Endoscopic Surgery™ (NOTES™) (e.g., StomaphyX™) • EndoBarrier™ Gastrointestinal Liner • Stomach aspiration therapy (e.g., Aspire Assist) • Vagus nerve blocking (e.g., VLOB device, also known as the Maestro Implant or Maestro Rechargeable System)
• Vertical Banded Gastroplasty (VBG)
• Biliopancreatic diversion (BPD) without duodenal switch • Laparoscopic gastric plication or laparoscopic greater curvature plication
• Roux-en-Y gastric bypass (short limb or long limb) combined with simultaneous gastric banding when used for GERD

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• Parietal cell separating gastrojejunostomy
• Endoscopic Sleeve Gastrectomy (ESG) (e.g. OverStitch NXT Endoscopic Suturing System) • Transoral outlet reduction endoscopy (TORe)

Policy Guidelines and Definitions

Adjustable Gastric Banding (AGB) - AGB achieves weight loss through gastric restriction only by an inflatable doughnut-shaped balloon band. This band creates a small gastric pouch. The pouch is located in the uppermost part of the stomach. The band can be adjusted by adding or removing saline through a port. AGB procedures are laparoscopic only.

Biliopancreatic Diversion with Duodenal Switch (BPD/DS) - BPD/DS partially resects the stomach with weight loss through gastric restriction and malabsorption. Meal size is not restricted and one can eat relatively normal- sized meals because of the malabsorption with bypass of the jejunum and duodenum. Partial BPD/DS involves resection of the greater curvature of the stomach. It preserves the pyloric sphincter and transects the duodenum with a duodeno-ileal anastomosis and a lower ileo-ileal anastomosis. BPD/DS can be open or laparoscopic.

Roux-en-Y Gastric Bypass (RYGBP) - RYGBP reduces the stomach to a small gastric pouch (30 cc). By doing this, it results in feelings of satiety after meals (small). Weight loss is achieved through gastric restriction and malabsorption. This pouch is joined to a segment of the jejunum, bypassing the duodenum and very proximal small intestine. This reduces absorption. RYGBP can be open or laparoscopic.

Sleeve Gastrectomy - Resection of the greater curvature of the stomach is done and by doing this, it results in a tube or sleeve shaped stomach. Since the pyloric sphincter is preserved, it results in a more physiologic transit of food from the stomach to the duodenum and avoids the dumping syndrome. Dumping syndrome occurs when there is an overly rapid transport of food through the stomach into the intestines.

Bariatric Surgery - Also known as weight-loss surgery: Performed on the gastrointestinal tract of obese people to alter the digestive process and induce weight loss.

Pickwickian Syndrome - Obesity hypoventilation syndrome that changes the balances of oxygen and carbon dioxide in the lungs.

Pseudotumor Cerebri - Disorder with elevated spinal fluid pressure in the brain (aka: idiopathic intracranial hypertension).

Transoral outlet reduction endoscopy (TORe) - A revisional therapy that can help manage weight regain after gastric bypass. During this procedure, an endoscopic suturing system is used to reduce the size of the gastrojejunal anastomosis. The goal is to delay gastric pouch emptying and enhance the sensation of satiety (fullness).

Endoscopic sleeve gastroplasty (ESG) - ESG uses an endoscopic suturing device to seal off most of the stomach, forcing ingested food through an open tube of stomach tissue that connects the esophagus to the small intestine. ESG reduces the capacity of the stomach, which induces satiety with lower food consumption, thereby achieving weight loss. Unlike conventional open or laparoscopic surgeries, in ESG, the excess stomach tissue is not surgically removed. Additional terms for ESG include accordion procedure, transoral gastroplasty, vertical sutured gastroplasty, and endoluminal vertical gastroplasty.

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Coding Guidance

CPT Codes

PA Requirement 43644
Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
Yes 43645
Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass
and small intestine reconstruction to limit absorption
Yes 43659 Unlisted laparoscopy procedure, stomach
Yes if related to a procedure listed in this policy 43770
Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components)
Yes 43771
Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric band component only
No 43772
Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric band component only
No 43773
Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric band component only
No 43774
Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric band and subcutaneous port components
No 43775
Longitudinal gastrectomy (i.e., sleeve gastrectomy)
Yes 43848 Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) Yes 43860 Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy Yes 43865 Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy Yes 43886
Gastric restrictive procedure, open; revision of subcutaneous port component only No 43887
Gastric restrictive procedure, open; removal of subcutaneous port component only No 43888
Gastric restrictive procedure, open; removal and replacement of subcutaneous port component Only No 43999 Unlisted procedure, stomach
Yes, if related to a procedure listed in this policy 43842
Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty
Yes 43843
Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty
Yes 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) Yes 43846
Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy
Yes

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43847
Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction
Yes 43290 Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon NOT COVERED 43291 Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s) NOT COVERED 43889 Gastric restrictive procedure, transoral, endoscopic sleeve gastroplasty (ESG), including argon plasma coagulation, when performed NOT COVERED (E&I) 44799 Unlisted procedure, small intestine

Yes, if related to a procedure listed in this policy C9784 Gastric restrictive procedure, endoscopic sleeve gastroplasty, with esophagogastroduodenoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components NOT COVERED (E&I) C9785 Endoscopic outlet reduction, gastric pouch application, with endoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components NOT COVERED (E&I)

CPT® Copyright 2026 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

Eisenberg, Dan, et al. 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) indications for metabolic and bariatric surgery.

2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery - Surgery for Obesity and Related Diseases (soard.org)

National Coverage Determination (NCD) for Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity (100.1).

https://www.cms.gov/medicare-coverage-database/search.aspx

MassHealth Medical necessity guidelines for Bariatric surgery: https://www.mass.gov/guides/masshealth- guidelines-for-medical-necessity-determination-for-bariatric-surgery

Hayes: Apollo ESG System (Apollo Endosurgery Inc.) for Endoscopic Sleeve Gastroplasty. Evolving Evidence Review Sep 11, 2024.

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Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 8/13/2002 Initial Policy Date 4/2023 Criteria re-ordered and clarified. No change to covered procedures.
1/2024 Added Line of Business Section 4/2024 MassHealth adults will use MassHealth criteria instead of HNE effective 7/1/2024. Other criteria clarified with no significant change.
2/2025 Updated commercial to follow Interqual criteria.
Updated References.

12/2025 Added Transoral outlet reduction endoscopy (TORe) to Experimental and Investigational (E&I) list. Added CPT 43889 for TORe to the policy as E&I. Added Endoscopic Sleeve Gastrectomy (ESG) to E&I list. Added CPT C9784 for TORe to the policy as E&I. Added CPT C9784 for TORe to the policy as E&I. Definitions updated.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England 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). Health New England 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 Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. 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. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.