Humana Bariatric Surgery Form

Description

Bariatric surgery, also known as weight loss surgery, is performed on the gastro-intestinal (GI) tract of an obese individual to alter the digestive process and induce weight loss. Bariatric surgical techniques may be classified as restrictive, malabsorptive or a combination of both. Restrictive procedures reduce the stomach size, thus decreasing the amount of food the stomach can hold. Malabsorptive procedures limit the amount of nutrients and calories that the body can absorb. Most procedures are performed using a laparoscopic or open approach, however endoscopic approaches are also being investigated.

Currently, the two most commonly performed bariatric procedures include:

• Roux-en-Y gastric bypass (RYGB) (open or laparoscopic) is a malabsorptive surgery and is generally known as gastric bypass. In this procedure, a small stomach pouch is created to restrict food intake. The rest of the stomach is bypassed via a Y-shaped segment of the small intestine, which reduces the amount of calories and nutrients the body absorbs. Long-limb RYGB is similar to standard RYGB, except that the limb through which food passes is longer and is typically performed to treat a super obese individual (defined as a body mass index [BMI] greater than or equal to 50 kg/m²).
• Sleeve gastrectomy (open or laparoscopic) involves the removal of the greater curvature of the stomach and approximately 80 percent of the stomach volume. While pyloric sphincter and stomach functions are preserved, the remaining stomach resembles a slender curved tube. Sleeve gastrectomy was originally the first step of a more extensive two step bariatric surgery (e.g., biliopancreatic diversion with duodenal switch), but may also be performed as a single stage primary procedure for a potential bariatric surgery candidate.

Examples of other bariatric procedures and techniques include, but may not be limited to, the following:

• Aspiration therapy device insertion (e.g., AspireAssist) involves the endoscopic surgical placement of a drainage tube in the stomach that connects to an externally accessible port that sits flush against abdominal skin. Approximately 20 to 30 minutes after eating each daily meal, the individual attaches external components which open the port valve. The stomach contents are drained, irrigated with water and drained again. This device was voluntarily withdrawn from the market in 2022. (Refer to Coverage Limitations section)
• Biliopancreatic diversion (BPD) consists of a partial gastrectomy (resection of the stomach) and gastroileostomy (surgical connection of the stomach to the ileum, the last section of small intestine). It allows for relatively normal meal size, since the most proximal areas of the small intestine are bypassed, and substantial malabsorption occurs. It is less frequently used than other types of procedures because of the high risk for nutritional deficiencies.
• Biliopancreatic diversion (BPD) with duodenal switch (DS), while similar to the above procedure, this technique leaves a larger portion of the stomach intact,

Bariatric Surgery

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 03/01/2023
Policy Number: HUM-0423-032

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• including the pyloric valve that regulates the release of stomach contents into the small intestine. It also keeps a small portion of the duodenum in the digestive pathway.
• Laparoscopic adjustable gastric banding (LAGB) (eg, Lap-Band) involves the placement of a hollow band around the upper end of the stomach, creating a small pouch and a narrow passage into the larger remainder of the stomach. The band is inflated with a saline solution, which can be increased or decreased over time to alter the size of the passage.
• Laparoscopic gastric plication is the creation of a smaller stomach pouch by folding and sewing the stomach. It may also be performed in conjunction with gastric banding, which purportedly increases early weight loss and decreases the need for band adjustments. (Refer to Coverage Limitations section)
• Laparoscopic mini gastric bypass-one anastomosis gastric bypass (MGB-OAGB) divides the stomach similar to a traditional gastric bypass, but instead of creating a Roux-en-Y connection, the jejunum is attached directly to the stomach. (Refer to Coverage Limitations section)
• Natural orifice transluminal endoscopic surgery (NOTES) is being explored for a variety of surgeries, including bariatric procedures. NOTES procedures are incisionless and performed with an endoscope passed through the mouth. Examples of NOTES techniques for bariatric purposes include, but may not be limited to, the following:
  1. Endoscopic gastrointestinal bypass device (EGIBD), also known as a duodenal jejunal bypass or gastrointestinal liner, is a removable barrier that extends from the upper segment of the GI tract (gastroesophageal junction or duodenum) to the jejunum. By lining the upper portion of the small intestine, it causes nutrient absorption to occur further along the GI tract, which purportedly affects hormone levels. The EndoBarrier is an example of an EGIBD, which is not yet US Food & Drug Administration (FDA) approved but is undergoing studies for the management of conditions such as diabetes and obesity. (Refer to Coverage Limitations section)
  2. Endoscopic sleeve gastroplasty (ESG) is an incisionless procedure in which the stomach is purportedly restricted with staples or sutures by using endoscopic surgical tools (eg, Apollo ESG) guided through the mouth and esophagus. (Refer to Coverage Limitations section)
  3. Intragastric balloon (IGB) insertion involves temporary endoscopic placement or deglutition (swallowing) of a silicone balloon or dual balloon system filled with air or saline solution into the stomach. The presence of the balloon conveys a sense of fullness and restricts the stomach volume, thereby purportedly decreasing food intake. Intragastric balloons differ in their insertion method, volume, duration in the stomach, adjustability and means of removal. These balloons are kept in place for 4 to 6 months and then removed endoscopically or excreted naturally, depending on the type. Examples of intragastric balloons include, but may not be limited to:
     • Allurion Gastric Balloon
     • Obalon Balloon System
     • Orbera Intragastric Balloon System
     • ReShape Integrated Dual Balloon System
     • Spatz3 Adjustable Gastric Balloon
     (Refer to Coverage Limitations section)
  4. Restorative obesity surgery, endoluminal (ROSE) procedure is suggested for the treatment of weight regain following gastric bypass surgery due to a gradual expansion of the gastric pouch.

Bariatric Surgery Effective Date: 01/01/2024

Revision Date: 01/01/2024

Review Date: 03/01/2023

Policy Number: HUM-0423-032

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The stomach is accessed orally via an endoscope and reduced in size using an endoscopic closure device. (Refer to Coverage Limitations section)

Tissue approximation and endoscopic closure devices are being developed for use in conjunction with various endoscopic procedures, including NOTES. Endoscopic closure devices proposed for use in conjunction with NOTES include, but may not be limited to, the OverStitch Endoscopic Suturing System and Over-The-Scope Clip (OTSC) System Set. (Refer to Coverage Limitations section)

Transoral outlet reduction (TORe) is an endoscopic method of correcting a dilated gastrojejunostomy outlet after Roux-en-Y in an individual experiencing weight regain due to a relaxed gastric outlet. The enlarged gastric outlet reduces the sense of fullness and allows greater amounts of food ingestion. (Refer to Coverage Limitations section)

TransPyloric Shuttle (TPS) is another kind of space occupying device intended to treat obesity by slowing gastric emptying. It consists of a large spherical bulb connected to a smaller cylindrical bulb by a flexible tether that is placed endoscopically into the stomach. It self-positions across the pylorus to create an intermittent obstruction to gastric outflow that purportedly delays gastric emptying. The device is temporary and intended for endoscopic removal after 12 months. (Refer to Coverage Limitations section)

Referred to as a single anastomosis duodenal switch (SADS) or stomach intestinal pylorus sparing surgery (SIPS), is an operation based on the biliopancreatic diversion with duodenal switch (BPD-DS), however the pylorus is able to be preserved. The reconstruction occurs in one loop, which purportedly reduces operating time and requires no mesenteric opening. (Refer to Coverage Limitations section)

Maestro Rechargeable System]), also referred to as gastric pacing or vagal nerve stimulation, involves laparoscopic placement of two leads (electrodes) in contact with vagal nerve trunks and a subcutaneously implanted neuromodulation device which is externally programmed to intermittently send electrical impulses via the implanted electrodes. The electrical impulses are purported to block vagus nerve signals in the abdominal region, inhibiting gastric motility and increasing satiety (feeling full). (Refer to Coverage Limitations section)

Vertical banded gastroplasty (VBG) (open or laparoscopic) involves removal of stomach tissue with the subsequent use of a band and staples to create a small stomach pouch. VBG has been largely replaced by other procedures deemed to be more successful regarding sustained weight loss and is therefore rarely performed. (Refer to Coverage Limitations section)

Bariatric Surgery Effective Date: 01/01/2024

Revision Date: 01/01/2024

Review Date: 03/01/2023

Policy Number: HUM-0423-032

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Sometimes a hernia may be detected during a bariatric surgical procedure and require repair.

Bariatric Surgery Effective Date: 01/01/2024

Revision Date: 01/01/2024

Review Date: 03/01/2023

Policy Number: HUM-0423-032

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

For information about paraesophageal hernia repair, please refer to Laparoscopic Hiatal Hernia Repair Medical Coverage Policy.

Bariatric Surgery Revision/Conversion

Revision of a bariatric surgery procedure and/or conversion from one type of bariatric surgery procedure to another type may be necessary due to insufficient weight loss despite postoperative compliance to dietary or behavior modifications, specific complications from the primary procedure, nutritional problems or other reasons. The revision performed and subsequent coverage depends on several factors, including the initial bariatric surgery performed and the type of complication that has occurred. (Refer to Coverage Limitations section)

Coverage Determination

Bariatric surgery may be excluded by certificate. Surgical procedures for the removal of excess skin and/or fat in conjunction with weight loss or weight loss surgery may also be excluded by certificate. Please consult the member’s individual certificate regarding Plan coverage.

Any state mandates for bariatric surgery take precedence over this medical coverage policy.

Services provided by a psychiatrist, psychologist or other behavioral health professionals are subject to the provisions of the applicable behavioral health benefit.

Commercial Plan members: requests for ANY bariatric surgery require review by a medical director.

ADULT Humana members 18 years of age or older may be eligible under the Plan for the following open or laparoscopic bariatric surgeries:

• Initial Bariatric Procedures
• Biliopancreatic diversion (BPD) with or without duodenal switch (DS); OR
• Laparoscopic adjustable gastric banding (LAGB) (eg, Lap-Band)*; OR
• Roux-en-Y gastric bypass (RYGB) (short or long limb); OR
• Sleeve gastrectomy

Humana members 18 years of age or older must meet ALL of the following criteria to be eligible for the above surgical treatments:

• BMI greater than or equal to 40 kg/m2; OR
• BMI greater than or equal to 35 kg/m2 with at least one of the following associated comorbidities:
  • Cardiovascular disease (eg, uncontrolled hypertension and/or uncontrolled hyperlipidemia); OR
  • Evidence of fatty liver disease (eg, nonalcoholic fatty liver disease [NAFLD], nonalcoholic steatohepatitis [NASH]); OR
  • Idiopathic intracranial hypertension (pseudotumor cerebri); OR
  • Joint disease (eg, osteoarthritis); OR
  • Life threatening cardiopulmonary conditions (eg, severe obstructive sleep apnea [apnea-hypopnea index greater than 30], obesity hypoventilation syndrome [or Pickwickian syndrome] or obesity related cardiomyopathy); OR
  • Type II diabetes;

AND all of the following:

• Clinical record** demonstrating that the individual has failed previous attempts to achieve and maintain weight loss with medically supervised nonsurgical treatment for obesity; AND
• Clinical record** of participation in and compliance with a multidisciplinary surgical preparatory regimen (within 6 months prior to surgery) which includes the following:

Bariatric Surgery Effective Date: 01/01/2024

Revision Date: 01/01/2024

Review Date: 03/01/2023

Policy Number: HUM-0423-032

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• Behavior modification regarding dietary intake and physical activity (unless medically contraindicated); AND
• Nutrition education/counseling with a dietician or nutritionist that addresses pre- and postoperative dietary intake expectations; AND
• Documentation of clearance from a cardiologist for an individual with elevated cardiac risk (eg, Class III or IV on the Revised Cardiac Risk Index [RCRI]) and/or history of cardiac disease (eg, decompensated heart failure, high-grade arrhythmias, myocardial infarction, unstable angina, valvular heart disease); AND
• If a tobacco smoker, documentation of smoking cessation program completion at least 6 weeks prior to the date of the anticipated surgery must be submitted; AND
• Individual is not currently pregnant or breastfeeding and is not planning to become pregnant within 18 months of surgery; AND
• Preoperative psychological evaluation and clearance by a licensed mental health professional (within 12 months prior to procedure) to rule out psychiatric disorders (eg, chemical dependency, eating disorders, major depression or schizophrenia), inability to provide informed consent or inability to comply with pre- and postoperative regimens

*Adjustments of gastric banding are considered integral to the office visit and not separately reimbursable. **Clinical record documentation must include a summary of historical (failed) weight loss attempts as well as details of present exercise program participation (eg, physical activity, workout plan), nutrition program (eg, calorie intake, meal plan, diet followed), BMI and/or weight loss.

Commercial Plan members: requests for ANY bariatric surgery require review by a medical director.

ADOLESCENT Bariatric Surgery

Effective Date: 01/01/2024

Revision Date: 01/01/2024

Review Date: 03/01/2023

Policy Number: HUM-0423-032

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Humana members 12-17 years of age may be eligible under the Plan for the following open or laparoscopic bariatric surgeries:

• Initial Bariatric Procedures
• Roux-en-Y gastric bypass (RYGB) (short or long limb); OR
• Sleeve gastrectomy

Humana members 12-17 years of age must meet ALL of the following criteria to be eligible for the above surgical treatments:

• BMI greater than or equal to 40 kg/m²; OR
• BMI greater than or equal to 35 kg/m² with at least one of the following significant comorbidities:
  • Cardiovascular disease (eg, uncontrolled hypertension and/or uncontrolled hyperlipidemia); OR
  • Evidence of fatty liver disease (eg, nonalcoholic fatty liver disease [NAFLD], nonalcoholic steatohepatitis [NASH]); OR
  • Idiopathic intracranial hypertension (pseudotumor cerebri); OR
  • Life threatening cardiopulmonary conditions (eg, severe obstructive sleep apnea [apnea-hypopnea index greater than 30], obesity hypoventilation syndrome [or Pickwickian syndrome] or obesity-related cardiomyopathy); OR
  • Orthopedic disease (eg, Blount’s disease, slipped capital femoral epiphysis); OR
  • Type II diabetes;

AND all of the following:

• Clinical record** demonstrating that the individual has failed previous attempts to achieve and maintain weight loss with medically supervised nonsurgical treatment for obesity; AND

Bariatric Surgery Effective Date: 01/01/2024

Revision Date: 01/01/2024

Review Date: 03/01/2023

Policy Number: HUM-0423-032

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

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• Clinical record** of participation in and compliance with a multidisciplinary surgical preparatory regimen (within 6 months prior to surgery) which includes the following:
• Behavior modification regarding dietary intake and physical activity (unless medically contraindicated); AND
• Nutrition education/counseling with a dietician or nutritionist that addresses pre- and postoperative dietary intake expectations; AND
• Documentation of clearance from a cardiologist for an individual with elevated cardiac risk (eg, Class III or IV on the Revised Cardiac Risk Index [RCRI]) and/or history of cardiac disease (eg, decompensated heart failure, high-grade arrhythmias, myocardial infarction, unstable angina, valvular heart disease); AND
• If a tobacco smoker, documentation of smoking cessation program completion at least 6 weeks prior to the date of the anticipated surgery must be submitted; AND
• Individual is not currently pregnant or breastfeeding and is not planning to become pregnant within 18 months of surgery; AND
• Letters of recommendation from the adolescent's pediatrician and bariatric surgeon verbalizing that the individual is an appropriate candidate for the procedure, including demonstration of the ability to adhere to postoperative regimens; AND
• Preoperative psychological evaluation and clearance by a licensed mental health professional (within 12 months prior to procedure) to rule out psychiatric disorders (eg, chemical dependency, eating disorders, major depression or schizophrenia), inability to provide informed consent or inability to comply with pre- and postoperative regimens

Commercial Plan members: requests for ANY bariatric surgery require review by a medical director.

Bariatric Surgery Effective Date: 01/01/2024

Revision Date: 01/01/2024

Review Date: 03/01/2023

Policy Number: HUM-0423-032

Page: 11 of 30

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Bariatric Surgery Revision/Conversion in Adults and Adolescents

Humana members may be eligible under the Plan for bariatric surgery revision/conversion when the following criteria are met:

• Bariatric surgery coverage is available under the individual's current Plan; AND
• Documentation of smoking cessation program completion (if a tobacco smoker) at least 6 weeks prior to the date of the anticipated surgery must be submitted; AND
• Major surgical complication resulting from the initial bariatric procedure or its mechanical failure (see also the Coverage Limitations section). Examples of such a complication may include, but are not limited to:
• Anastomotic leak or stricture; OR
• Band erosion; OR
• Band migration (slippage) with documentation that it was unable to be corrected with a manipulation or an adjustment; OR
• Bowel obstruction or perforation; OR
• Candy cane syndrome (Roux syndrome) when an individual is symptomatic (eg, abdominal pain, emesis, nausea) and diagnosis has been confirmed by endoscopy or upper gastrointestinal contrast studies; OR
• Fistula; OR
• GI bleeding; OR
• Postoperative gastroesophageal reflux disease (GERD) refractory to maximum medical treatment including both over-the-counter and prescribed anti-reflux medications; OR
• Staple line dehiscence; OR

Bariatric Surgery Effective Date: 01/01/2024

Revision Date: 01/01/2024

Review Date: 03/01/2023

Policy Number: HUM-0423-032

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• Stomal stenosis

Note: The criteria for bariatric/obesity surgery are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Note: The criteria for intragastric (gastric) balloons are consistent with the Medicare National Coverage Policy, and therefore apply to Medicare members.

Coverage Limitations

Humana members may NOT be eligible under the Plan for bariatric surgery (including revisions/conversions) for any indications other than those listed above or for any other surgical treatments for severe obesity including, but may not be limited to, the following:

• Aspiration therapy (eg, AspireAssist); OR
• Laparoscopic gastric plication; OR
• Mini gastric bypass-one anastomosis gastric bypass (MGB-OAGB); OR
• Natural orifice transluminal endoscopic surgery (NOTES) techniques for bariatric surgery including, but may not be limited to, the following:
  • Endoscopic gastrointestinal bypass device (EGIBD) (also known as a duodenal jejunal bypass or gastrointestinal liner [eg, EndoBarrier]); OR
  • Endoscopic sleeve gastroplasty (ESG) (eg, Apollo ESG); OR
  • Intragastric balloon (eg, Allurion, Obalon, Orbera, ReShape, Spatz3); OR
  • Restorative obesity surgery, endoluminal (ROSE); OR
  • Transoral outlet reduction (TORe); OR
  • TransPyloric Shuttle (TPS) device; OR
• Use of any endoscopic closure device (eg, OverStitch Endoscopic Suturing System, Over-The-Scope Clip [OTSC] System Set) in conjunction with NOTES; OR
• Single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) (also known as single anastomosis duodenal switch [SADS] or stomach intestinal pylorus sparing surgery [SIPS]); OR
• Vagus/vagal nerve blocking (VBLOC) (eg, Maestro), also referred to as gastric pacing or vagal nerve stimulation; OR
• Vertical banded gastroplasty (VBG) (open or laparoscopic)

These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible for bariatric surgery revision/conversion due to inadequate weight loss, stretching or pouch dilatation related to dietary or behavior modification noncompliance or subsequent postoperative weight regain as it is not considered to be a mechanical failure or major surgical complication. This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for any other surgical procedures related to obesity including, but may not be limited to, the following:

• Liposuction (eg, suction assisted lipectomy, ultrasonic assisted liposuction); OR
• Surgical procedures for the removal of excess skin and/or fat in conjunction with, or resulting from, weight loss or weight loss surgery (may be excluded by certificate)

Bariatric Surgery Effective Date: 01/01/2024

Revision Date: 01/01/2024

Review Date: 03/01/2023

Policy Number: HUM-0423-032

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Bariatric Surgery Effective Date: 01/01/2024

Revision Date: 01/01/2024

Review Date: 03/01/2023

Policy Number: HUM-0423-032

Page: 14 of 30

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

These are considered cosmetic and are performed to improve or change appearance or self-esteem. Please refer to the member’s individual certificate for the specific definition.

For information regarding cosmetic surgery, please refer to Cosmetic and Reconstructive Surgery Medical Coverage Policy.

For information regarding other surgical procedures for the removal of excess skin and/or fat, please refer to Panniculectomy, Abdominoplasty, Abdominal Contouring Medical Coverage Policy.

Intraoperative endoscopy is considered integral to the primary procedure and not separately reimbursable.

Background

Additional information about obesity may be found from the following websites:

• Centers for Disease Control and Prevention
• National Institute of Diabetes and Digestive and Kidney Diseases
• National Library of Medicine

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

Provider Claims Codes

Bariatric Surgery Effective Date: 01/01/2024

Revision Date: 01/01/2024

Review Date: 03/01/2023

Policy Number: HUM-0423-032

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

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Bariatric Surgery Effective Date: 01/01/2024

Revision Date: 01/01/2024

Review Date: 03/01/2023

Policy Number: HUM-0423-032

Page: 16 of 30

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Bariatric Surgery Effective Date: 01/01/2024

Revision Date: 01/01/2024

Review Date: 03/01/2023

Policy Number: HUM-0423-032

Page: 17 of 30

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

References

• Agency for Healthcare Research and Quality (AHRQ). Technology Assessment. Short-and long-term bariatric surgery in the Medicare population. https://www.ahrq.gov. Published January 7, 2018.

Accessed January 19, 2023.

Bariatric Surgery Effective Date: 01/01/2024

Revision Date: 01/01/2024

Review Date: 03/01/2023

Policy Number: HUM-0423-032

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

American Academy of Pediatrics (AAP). Clinical Practice Guideline. Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. https://www.aap.org. Published February 2023. Accessed January 30, 2023.

American Academy of Pediatrics (AAP). Policy Statement. Pediatric metabolic and bariatric surgery: evidence, barriers, and best practices. https://www.aap.org. Published December 2019. Accessed January 30, 2023.

American Academy of Pediatrics (AAP). Technical Report. Metabolic and bariatric surgery for pediatric patients with severe obesity. https://www.aap.org. Published December 2019. Accessed January 30, 2023.

American Association for the Study of Liver Diseases (AASLD). Practice Guidance. The diagnosis and management of nonalcoholic fatty liver disease: practice guidance from the American Associations for the Study of Liver Diseases. https://www.aasld.org. Published January 2018. Accessed January 31, 2023.

American Association of Clinical Endocrinologists (AACE). AACE/ACE Guidelines. American Association of Clinical Endocrinologists and American College of Endocrinology comprehensive clinical practice guidelines for medical care of patients with obesity. https://www.aace.com. Published July 2016. Accessed January 31, 2023.

American College of Cardiology (ACC). 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults. https://www.acc.org. Published July 1, 2014. Accessed January 31, 2023.

American College of Obstetricians and Gynecologists (ACOG). Committee Opinion. Obesity in adolescents. https://www.acog.org. Published September 2017. Updated 2021. Accessed February 2, 2023.

American College of Obstetricians and Gynecologists (ACOG). Obstetric Care Consensus. Interpregnancy care. https://www.acog.org. Published January 2019. Updated 2021. Accessed February 2, 2023.

Bariatric Surgery Effective Date: 01/01/2024

Revision Date: 01/01/2024

Review Date: 03/01/2023

Policy Number: HUM-0423-032

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

10. American College of Obstetricians and Gynecologists (ACOG). Practice Bulletin. Bariatric surgery and pregnancy. https://www.acog.org. Published June 2009. Updated November 2021. Accessed February 2, 2023.
11. American Diabetes Association (ADA). Obesity and weight management for the prevention and treatment of type 2 diabetes: standards of care in diabetes – 2023. https://www.diabetes.org. Published January 2023. Accessed January 31, 2023.
12. American Gastroenterological Association (AGA). Clinical Practice Guidelines. AGA clinical practice guidelines on intragastric balloons in the management of obesity. https://www.gastro.org. Published April 2021. Accessed February 2, 2023.
13. American Heart Association (AHA). Obesity and cardiovascular disease: a scientific statement from the American Heart Association. https://www.heart.org. Published May 2021. Accessed January 31, 2023.
14. American Society for Gastrointestinal Endoscopy (ASGE). ASGE Technology Committee Systematic Review and Meta-Analysis. ASGE bariatric endoscopy task force systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting endoscopic bariatric therapies. https://www.asge.org. Published September 2015. Accessed February 2, 2023.

16. American Society for Gastrointestinal Endoscopy (ASGE). Guideline. The role of endoscopy in the bariatric surgery patient. https://www.asge.org. Published May 2015. Accessed February 2, 2023.
17. American Society for Gastrointestinal Endoscopy (ASGE). Position Statement. ASGE position statement on endoscopic bariatric therapies in clinical practice. https://www.asge.org. Published June 22, 2015. Accessed February 2, 2023.
18. American Society for Gastrointestinal Endoscopy (ASGE). Quality Indicators for GI Endoscopic Procedures. Quality indicators for EGD. https://www.asge.org. Published 2015. Accessed February 2, 2023.

Bariatric Surgery Effective Date: 01/01/2024

Revision Date: 01/01/2024

Review Date: 03/01/2023

Policy Number: HUM-0423-032

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

18. American Society for Gastrointestinal Endoscopy (ASGE). Report on Emerging Technology (ARCHIVED). Endoluminal bariatric techniques. https://www.asge.org. Published 2012. Accessed February 2, 2023.
19. American Society for Gastrointestinal Endoscopy (ASGE). Status Evaluation Report (ARCHIVED). Endoscopic bariatric therapies. https://www.asge.org. Published May 2015. Accessed February 2, 2023.
20. American Society for Gastrointestinal Endoscopy (ASGE). Technical Status Evaluation Report. Endoscopic devices and techniques for the management of bariatric surgical adverse events (with videos). https://www.asge.org. Published 2020. Accessed February 2, 2023.

Bariatric Surgery Effective Date: 01/01/2024

Revision Date: 01/01/2024

Review Date: 03/01/2023

Policy Number: HUM-0423-032

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21. American Society for Metabolic and Bariatric Surgery (ASMBS). American Society for Metabolic and Bariatric Surgery and American Hernia Society consensus guideline on bariatric surgery and hernia surgery. https://www.asmbs.org. Published July 5, 2018. Accessed January 26, 2023.
22. American Society for Metabolic and Bariatric Surgery (ASMBS). ASMBS Guidelines/Statements. American Society of Metabolic and Bariatric Surgery consensus statement on laparoscopic adjustable gastric band management. https://www.asmbs.org. Published June 26, 2022. Accessed January 26, 2023.
23. American Society for Metabolic and Bariatric Surgery (ASMBS). ASMBS Guidelines/Statements. American Society for Metabolic and Bariatric Surgery position statement on intragastric balloon therapy endorsed by the Society of American Gastrointestinal and Endoscopic Surgeons. https://www.asmbs.org. Published December 18, 2015. Updated January 2018. Accessed January 26, 2023.
24. American Society for Metabolic and Bariatric Surgery (ASMBS). ASMBS Guidelines/Statements. American Society for Metabolic and Bariatric Surgery position statement on vagal blocking therapy for obesity. https://www.asmbs.org. Published December 3, 2015. Accessed January 26, 2023.

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Review Date: 03/01/2023

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25. American Society for Metabolic and Bariatric Surgery (ASMBS). ASMBS Guidelines/Statements. American Society for Metabolic and Bariatric Surgery updated position statement on sleeve gastrectomy as a bariatric procedure. https://www.asmbs.org. Published August 9, 2017. Accessed January 26, 2023.
26. American Society for Metabolic and Bariatric Surgery (ASMBS). ASMBS Guidelines/Statements. American Society for Metabolic and Bariatric Surgery updated statement on single-anastomosis duodenal switch. https://www.asmbs.org. Published March 16, 2020. Accessed January 26, 2023.

28. American Society for Metabolic and Bariatric Surgery (ASMBS). ASMBS Guidelines/Statements. ASMBS position statement in the relationship between obesity and cancer, and the role of bariatric surgery: risk, timing of treatment, effects on disease biology, and qualification for surgery. https://www.asmbs.org. Published March 16, 2020. Accessed January 26, 2023.
29. American Society for Metabolic and Bariatric Surgery (ASMBS). ASMBS Guidelines/Statements. ASMBS updated position statement on insurance mandated preoperative weight loss requirements. https://www.asmbs.org. Published April 18, 2016. Accessed January 26, 2023.
30. American Society for Metabolic and Bariatric Surgery (ASMBS). ASMBS Guidelines/Statements. Recommendations for the presurgical psychosocial evaluation of bariatric surgery patients. https://www.asmbs.org. Published February 5, 2016. Accessed January 26, 2023.
31. American Society for Metabolic and Bariatric Surgery (ASMBS). ASMBS policy statement on gastric plication. https://www.asmbs.org. Published March 8, 2011. Accessed January 26, 2023.
32. American Society for Metabolic and Bariatric Surgery (ASMBS). ASMBS Statements/Guidelines. ASMBS updated position statement on bariatric surgery in class I obesity (BMI 30-35 kg/m2). https://www.asmbs.org. Published May 31, 2018. Accessed January 26, 2023.

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Revision Date: 01/01/2024

Review Date: 03/01/2023

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32. American Society for Metabolic and Bariatric Surgery (ASMBS). Consensus Conference Statement. Bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. https://www.asmbs.org. Published March 2005. Accessed January 26, 2023.
33. American Society for Metabolic and Bariatric Surgery (ASMBS). Guidelines. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures – 2019 update: cosponsored by American Association of Clinical Endocrinologists/ American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. https://www.asmbs.org. Published 2019. Accessed January 26, 2023.
34. American Society for Metabolic and Bariatric Surgery (ASMBS). Guidelines/ Statements. ASMBS position statement on preoperative patient optimization before metabolic and bariatric surgery. https://www.asmbs.org. Published August 27, 2021. Accessed January 26, 2023.
35. American Society for Metabolic and Bariatric Surgery (ASMBS). Original Article. 2022 American Society for Metabolic and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): indications for metabolic and bariatric surgery. https://www.asmbs.org. Published August 5, 2022. Accessed January 26, 2023.
36. American Society for Metabolic and Bariatric Surgery (ASMBS). Original Article. ASMBS position statement on the impact of metabolic and bariatric surgery on nonalcoholic steatohepatitis. https://www.asmbs.org. Published November 7, 2021. Accessed January 26, 2023.
37. American Society for Metabolic and Bariatric Surgery (ASMBS). Review Article. ASMBS pediatric metabolic and bariatric surgery guidelines, 2018. https://www.asmbs.org. Published March 21, 2018. Accessed January 26, 2023.

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Review Date: 03/01/2023

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38. American Society for Metabolic and Bariatric Surgery (ASMBS). Review Article. Systematic review on reoperative bariatric surgery. Published February 10, 2014. Accessed January 26, 2023.
39. American Society for Metabolic and Bariatric Surgery (ASMBS). Update. American Society for Metabolic and Bariatric Surgery position statement on emerging endosurgical interventions for treatment of obesity. Published February 4, 2009. Accessed January 26, 2023.
40. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Bariatric surgery for treatment of morbid obesity (100.1). Published September 24, 2013. Accessed January 23, 2023.
41. ClinicalKey. Clinical Overview. Obesity in adults. Updated July 16, 2022. Accessed January 23, 2023.
42. ClinicalKey. Clinical Overview. Obesity in children. Updated April 26, 2022. Accessed January 23, 2023.
43. ClinicalKey. Clinical Overview. Obesity, surgical management. Updated September 9, 2022. Accessed January 23, 2023.
44. ClinicalKey. Ferri FF. Obesity. In: Ferri FF. Ferri's Clinical Advisor 2023. Elsevier; 2023:1078-1082.e1. https://www.clinicalkey.com. Accessed January 23, 2023.
45. ClinicalKey. Jensen MD. Obesity. In: Goldman L. Goldman-Cecil Medicine. 26th ed. Elsevier; 2020:1418-1427.e3. https://www.clinicalkey.com. Accessed January 23, 2023.
46. ClinicalKey. Shah M. Obesity in adults. In: Kellerman RD. Conn’s Current Therapy 2023. Elsevier; 2023:376-382. https://www.clinicalkey.com. Accessed January 23, 2023.

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47. ECRI Institute. Clinical Evidence Assessment. AspireAssist Gastric Aspiration Port (Aspire Bariatrics, Inc.) for treating obesity. Published July 5, 2016. Updated February 19, 2021. Accessed January 10, 2023.
48. ECRI Institute. Clinical Evidence Assessment. Orbera Intragastric Balloon (Apollo Endosurgery, Inc.) for treating obesity. Published September 22, 2015. Updated February 10, 2021. Accessed January 10, 2023.
49. ECRI Institute. Clinical Evidence Assessment. Outpatient laparoscopic adjustable gastric band surgery. Published September 16, 2022. Accessed January 12, 2023.
50. ECRI Institute. Clinical Evidence Assessment. Outpatient Roux-en-Y gastric bypass surgery for treating obesity. Published September 16, 2022. Accessed January 12, 2023.
51. ECRI Institute. Clinical Evidence Assessment. Outpatient sleeve gastrectomy for treating obesity. Published September 16, 2022. Accessed January 12, 2023.
52. ECRI Institute. Clinical Evidence Assessment. Repeat bariatric surgery for treating obesity. Published September 26, 2014. Updated January 27, 2021. Accessed January 10, 2023.
53. ECRI Institute. Clinical Evidence Assessment. Spatz3 Adjustable Gastric Balloon (Spatz FGIA, Inc.) for treating obesity. Published January 11, 2022. Accessed January 10, 2023.
54. ECRI Institute. Emerging Technology Evidence Report. Intragastric balloons (Obalon, Orbera, and ReShape) for treating obesity. Published March 1, 2017. Updated August 22, 2017. Accessed January 10, 2023.

Metabolic surgery for resolving type 2 diabetes mellitus in patients with BMI <35 kg/m².

Bariatric Surgery Effective Date: 01/01/2024

Revision Date: 01/01/2024

Review Date: 03/01/2023

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56. ECRI Institute. Emerging Technology Evidence Report. Rechargeable vagal blocking system (Maestro) for treating obesity. https://www.ecri.org. Published July 28, 2016. Updated May 25, 2017. Accessed January 12, 2023.

57. ECRI Institute. Health Technology Forecast. Metabolic surgery for treating type 2 diabetes mellitus regardless of patient BMI. https://www.ecri.org. Published July 22, 2009. Updated August 19, 2015. Accessed January 12, 2023.

58. ECRI Institute. Hotline Response. Ingestible intragastric balloons for treating obesity. https://www.ecri.org. Published April 15, 2020. Accessed January 10, 2023.

59. ECRI Institute. Hotline Response (ARCHIVED). Laparoscopic sleeve gastrectomy for morbid obesity. https://www.ecri.org. Published March 24, 2006. Updated January 5, 2012. Accessed January 12, 2023.

60. ECRI Institute. Product Brief. TransPyloric Shuttle Implant (BAROnova, Inc.) for treating obesity. https://www.ecri.org. Published May 21, 2019. Accessed January 12, 2023.

61. Endocrine Society. Clinical Practice Guideline. Pediatric obesity – assessment, treatment, and prevention: an Endocrine Society clinical practice guideline. https://www.endocrine.org. Published March 2017. Accessed January 31, 2023.

62. Hayes, Inc. Clinical Research Response (ARCHIVED). AspireAssist (Aspire Bariatrics) aspiration therapy for weight loss in obese individuals. https://evidence.hayesince.com. Published April 15, 2021. Accessed January 12, 2023.

63. Hayes, Inc. Emerging Technology Report (ARCHIVED). Transpyloric shuttle device. https://evidence.hayesinc.com. Published April 25, 2019. Accessed January 12, 2023.

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Revision Date: 01/01/2024

Review Date: 03/01/2023

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64. Hayes, Inc. Evolving Evidence Review. OverStitch Endoscopic Suturing System (Apollo Endosurgery Inc.) for endoscopic sleeve gastrectomy. https://evidence.hayesinc.com. Published May 9, 2022. Accessed January 12, 2023.

65. Hayes, Inc. Evolving Evidence Review. OverStitch Endoscopic Suturing System (Apollo Endosurgery Inc.) for transoral outlet reduction. https://evidence.hayesinc.com. Published July 22, 2022. Accessed January 12, 2023.

66. Hayes, Inc. Health Technology Brief (ARCHIVED). Laparoscopic ileal interposition and sleeve gastrectomy for treatment of type 2 diabetes. https://evidence.hayesinc.com. Published February 16, 2009. Updated March 3, 2011. Accessed January 16, 2023.

67. Hayes, Inc. Health Technology Brief (ARCHIVED). Laparoscopic mini-gastric bypass for morbid obesity. https://evidence.hayesinc.com. Published August 28, 2006. Updated September 16, 2008. Accessed January 16, 2023.

68. Hayes, Inc. Health Technology Brief (ARCHIVED). Laparoscopic sleeve gastrectomy for super obesity in adults. https://evidence.hayesinc.com. Published October 19, 2012. Updated September 15, 2016. Accessed January 16, 2023.

69. Hayes, Inc. Health Technology Brief (ARCHIVED). Maestro rechargeable system (EnteroMedics Inc.) for vagal blocking for obesity control. https://evidence.hayesinc.com. Published February 4, 2016.

Updated February 1, 2018. Accessed January 16, 2023.

70. Hayes, Inc. Health Technology Brief (ARCHIVED). Single-anastomosis duodenal switch for weight loss. https://evidence.hayesinc.com. Published February 7, 2018. Updated March 13, 2020. Accessed January 16, 2023.

71. Hayes, Inc. Medical Technology Directory. Comparative effectiveness review of bariatric surgeries for treatment of obesity in adolescents. https://evidence.hayesinc.com. Published January 21, 2019. Updated January 20, 2022. Accessed January 16, 2023.

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Review Date: 03/01/2023
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72. Hayes, Inc. Medical Technology Directory. Comparative effectiveness review of mini gastric bypass – one anastomosis gastric bypass for the treatment of obesity: a review of reviews. https://evidence.hayesinc.com. Published May 30, 2019. Updated January 20, 2023. Accessed January 23, 2023.

73. Hayes, Inc. Medical Technology Directory. Impact of preoperative supervised weight loss programs on bariatric surgery outcomes. https://evidence.hayesinc.com. Published December 19, 2017. Updated January 18, 2022. Accessed January 16, 2023.

74. Hayes, Inc. Medical Technology Directory. Intragastric balloons for the treatment of obesity. https://evidence.hayesinc.com. Published March 29, 2018. Updated March 16, 2022. Accessed January 16, 2023.

75. Hayes, Inc. Medical Technology Directory (ARCHIVED). Comparative effectiveness of Roux-en-Y gastric bypass and sleeve gastrectomy for treatment of type 2 diabetes: a review of reviews. https://evidence.hayesinc.com. Published July 27, 2017. Updated September 10, 2021. Accessed January 16, 2023.

76. Hayes, Inc. Medical Technology Directory (ARCHIVED). Laparoscopic bariatric surgery: Roux-en-Y gastric bypass, vertical banded gastroplasty and adjustable gastric banding. https://evidence.hayesinc.com. Published June 7, 2007. Updated June 24, 2011. Accessed January 16, 2023.

77. Hayes, Inc. Medical Technology Directory (ARCHIVED). Malabsorptive bariatric surgery: open and laparoscopic biliopancreatic diversion. https://evidence.hayesinc.com. Published June 7, 2007. Updated June 28, 2011. Accessed January 16, 2023.

78. Hayes, Inc. Medical Technology Directory (ARCHIVED). Open malabsorptive bariatric surgery: Roux-en-Y gastric bypass. https://evidence.hayesinc.com. Published June 7, 2007. Updated June 29, 2011. Accessed January 16, 2023.

79. Hayes, Inc. Medical Technology Directory (ARCHIVED). Open restrictive bariatric surgery: gastroplasty and gastric banding.https://evidence.hayesinc.com. Published June 7, 2007. Updated June 22, 2011. Accessed January 16, 2023.

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80. Hayes, Inc. Medical Technology Directory (ARCHIVED). Revisional surgery for treatment of complications after bariatric surgery. https://evidence.hayesinc.com. Published July 24, 2014. Updated July 26, 2018. Accessed January 16, 2023.

81. Hayes, Inc. Medical Technology Directory (ARCHIVED). Roux-en-Y gastric bypass for treatment of type 2 diabetes: a review of reviews. https://evidence.hayesinc.com. Published May 25, 2017. Updated June 22, 2021. Accessed January 16, 2023.

82. Heart Failure Society of America (HFSA). Consensus Statement.

1. Nutrition, obesity, and cachexia in patients with heart failure: a consensus statement from the Heart Failure Society of America Scientific Statements Committee. https://www.hfsa.org. Published 2019. Accessed January 31, 2023.
2. MCG Health. Gastric restrictive procedure, sleeve gastrectomy by laparoscopy. 26th edition. https://www.mcg.com. Accessed December 19, 2022.
3. MCG Health. Gastric restrictive procedure with gastric bypass. 26th edition. https://www.mcg.com. Accessed December 19, 2022.
4. MCG Health. Gastric restrictive procedure with gastric bypass by laparoscopy. 26th edition. https://www.mcg.com. Accessed December 19, 2022.
5. MCG Health. Gastric restrictive procedure without gastric bypass by laparoscopy. 26th edition. https://www.mcg.com. Accessed December 19, 2022.
6. National Heart, Lung and Blood Institute (NHLBI). Evidence Report. Managing overweight and obesity in adults: systematic evidence review from the obesity expert panel, 2013. https://www.nhlbi.nih.gov. Published November 2013. Accessed January 31, 2023.

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88. North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASGHAN). Clinical Guidelines. NASGHAN clinical practice guideline for the diagnosis and treatment of nonalcoholic fatty liver disease in children. https://www.naspghan.org. Published February 2017. Accessed February 2, 2023.
89. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Guidelines for clinical application of laparoscopic bariatric surgery. https://www.sages.org. Published June 2008. Accessed February 2, 2023.
90. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Updated Panel Report. Best practices for the surgical treatment of obesity. https://www.sages.org. Published February 2018. Accessed February 2, 2023.
91. UpToDate, Inc. Bariatric operations: early (fewer than 30 days) morbidity and mortality. https://www.uptodate.com. Updated December 2022. Accessed January 24, 2023.
92. UpToDate, Inc. Bariatric procedures for the management of severe obesity: descriptions. https://www.uptodate.com. Updated December 2022. Accessed January 24, 2023.
93. UpToDate, Inc. Bariatric surgery for management of obesity: indications and preoperative preparation. https://www.uptodate.com. Updated January 4, 2023. Accessed January 24, 2023.
94. UpToDate, Inc. Clinical presentation and diagnosis of obstructive sleep apnea in adults. https://www.uptodate.com. Updated January 13, 2023. Accessed January 24, 2023.
95. UpToDate, Inc. Evaluation of cardiac risk prior to noncardiac surgery. https://www.uptpdate.com. Updated December 2022. Accessed January 24, 2023.
96. UpToDate, Inc. Gastrointestinal endoscopy in patients who have undergone bariatric surgery. https://www.uptodate.com. Updated December 2022. Accessed January 24, 2023.

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100. UpToDate, Inc. Late complications of bariatric surgical operations. https://www.uptodate.com. Updated December 2022. Accessed January 24, 2023.
101. UpToDate, Inc. Normal puberty. https://www.uptodate.com. Updated January 18, 2023. Accessed January 24, 2023.
102. UpToDate, Inc. Obesity in adults: overview of management. https://www.uptodate.com. Updated December 2022. Accessed January 24, 2023.
103. UpToDate, Inc. Outcomes of bariatric surgery. https://www.uptodate.com. Updated December 2022. Accessed January 24, 2023.
104. UpToDate, Inc. Surgical management of severe obesity in adolescents. https://www.uptodate.com. Updated December 2022. Accessed January 24, 2023.