Point32 Bariatric Surgeries Form
Harvard Pilgrim Health Care Commercial Products:
Harvard Pilgrim Health Care (HPHC) has designated selected in-network facilities as Weight Loss Surgery Centers of Excellence (COE); these facilities provide access to integrated programs focused on patient health, safety and cross-functional team support, and have met stringent quality criteria established by the American College of Surgeons and/or the American Society for Metabolic and Bariatric Surgery.
- A list of designated Weight Loss Surgery Centers of Excellence is published on HPHC’s public website: https://www.harvardpilgrim.org/public/find-a-provider
- To ensure quality of care, HMO members should be directed to a designated Weight Loss Surgery Center of Excellence.
- For POS and PPO members, medically necessary procedures performed at designated Centers of Excellence facilities are covered at in-network cost; procedures performed at non-COE facilities may be covered at out-of-network benefits levels.
Tufts Health Plan Commercial HMO and EPO Products:
Bariatric surgery must be performed at facilities in the Designated Provider Network for Bariatric Surgery (DPNBS) in order for the procedure to be covered for HMO and EPO Members.
Tufts Health Plan Commercial POS and PPO Products:
If POS and PPO Members want to receive coverage at the authorized/In-network level of benefits, bariatric surgery must be performed at one of the facilities in the Designated Provider Network for Bariatric Surgery (DPNBS). For POS/ PPO Members, if bariatric surgery is not performed at a DPNBS facility, coverage will be provided at the unauthorized/out of network level of benefits.
Tufts Health Plan Public Plan Products:
Bariatric surgery must be performed at facilities in the Designated Provider Network for Bariatric Surgery (DPNBS) in order for the procedure to be covered for Public Plan Members
Clinical Guideline Coverage Criteria
The Plan requires the use of InterQual® Subsets or SmartSheets for the following procedures:
- Revisional Procedure – Adult (Version 2022)
- Laparoscopic Adjustable Gastric Band (Repair, Revision) – Adult (Version 2022)
- Laparoscopic Adjustable Gastric Band (Removal) – Adult (Version 2022)
- Adjustment of Gastric Band Diameter – Adult (Version 2022)
- Biliopancreatic Diversion with Duodenal Switch – Adult (Version 2022)
- Roux-en-Y Gastric Bypass - Adult (Version 2022)
- Sleeve Gastrectomy - Adult (Version 2022)
- Laparoscopic Adjustable Gastric Band - Adult (Version 2022)
For this policy, The Plan draws upon the following InterQual® criteria:
- Roux-en-Y Gastric Bypass - Adolescent (Version 202)
- Sleeve Gastrectomy - Adolescent (Version 2022)
- Revisional Procedure – Adolescent (Version 2022)
- Laparoscopic Adjustable Gastric Band (Removal) – Adolescent (Version 2022)
- Laparoscopic Adjustable Gastric Band (Repair Revision) – Adolescent (Version 2022)
Limitations
The Plan considers the following procedures to be investigational and, therefore, not medically necessary:
- Intragastric balloon procedures for the treatment of obesity (e.g. Orbera Intragastric Balloon System, ReShape Integrated Dual Balloon System)
- Endoscopic sclerotherapy for bariatric indications (e.g. revision of Roux-en-Y procedure to address weight regain) and endoscopic gastric suturing (e.g. with the Apollo Overstitch™ System) for revision of gastric bypass or as a primary bariatric procedure
- Single anastomosis gastric bypass (also referred to as “mini gastric bypass”)
- TransPyloric Shuttle
- Bariatric Surgery, Adjustable Gastric Banding in Adolescents