Point32 Bariatric Surgery(Eff. beginning 1.1.24) 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 uses guidance from the Centers for Medicare and Medicaid Services (CMS) and MassHealth for coverage determinations for its Dual Product Eligible plan Members. CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs) and documentation included in the Medicare manuals and MassHealth Medical Necessity Determinations are the basis for coverage determinations where available. For Tufts Health One Care plan Members, the following criteria is used:

• NCD – Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity (100.1)

The Plan requires the use of InterQual® Subsets or SmartSheets for the following procedures:

1. Revisional Procedure – Adult
2. Laparoscopic Adjustable Gastric Band (Repair, Revision) – Adult
3. Laparoscopic Adjustable Gastric Band (Removal) – Adult
4. Adjustment of Gastric Band Diameter – Adult
5. Biliopancreatic Diversion with Duodenal Switch – Adult
6. Roux-en-Y Gastric Bypass - Adult
7. Sleeve Gastrectomy - Adult
8. Laparoscopic Adjustable Gastric Band - Adult

For this policy, The Plan draws upon the following InterQual® criteria:

1. Roux-en-Y Gastric Bypass - Adolescent
2. Sleeve Gastrectomy - Adolescent
3. Revisional Procedure – Adolescent
4. Laparoscopic Adjustable Gastric Band (Removal) – Adolescent
5. Laparoscopic Adjustable Gastric Band (Repair Revision) – Adolescent

Limitations

Bariatric Surgery2The Plan considers the following procedures to be investigational and, therefore, not medically necessary:

1. Intragastric balloon procedures for the treatment of obesity (e.g., Orbera Intragastric Balloon System, ReShape Integrated Dual Balloon System)
2. 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
3. Single anastomosis gastric bypass (also referred to as “mini gastric bypass”)
4. TransPyloric Shuttle
5. Bariatric Surgery, Adjustable Gastric Banding in Adolescents

Codes