Point32Commercial Clinical Policy

Point32 Bariatric Surgery Form


Notes: For information about paraesophageal hernia repair during bariatric surgery, refer to Laparoscopic Hiatal Hernia Repair Medical Coverage Policy. 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.

Indications

(582331) Is the bariatric surgery revision/conversion being considered due to insufficient weight loss despite postoperative compliance to dietary or behavior modifications? 
(582332) Is the procedure being considered due to specific complications from the primary bariatric procedure? 
(582333) Is the bariatric surgery revision necessary due to nutritional problems? 
(582334) Is the revision or conversion requested by a Commercial Plan member? 

Contraindications

(582335) Is bariatric surgery explicitly excluded by the patient's certificate? 
YesNoN/A
YesNoN/A

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Effective Date

01/01/2024

Last Reviewed

03/01/2023

Original Document

  Reference



References

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  7. Bariatric Surgery Effective Date: 01/01/2024 Revision Date: 01/01/2024 Review Date: 03/01/2023 Policy Number: HUM-0423-032 Page: 24 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.

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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.

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    See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

    Bariatric Surgery Effective Date: 01/01/2024 Revision Date: 01/01/2024 Review Date: 03/01/2023 Policy Number: HUM-0423-032 Page: 26 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.

  • 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.

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    • See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

    Bariatric Surgery Effective Date: 01/01/2024 Revision Date: 01/01/2024 Review Date: 03/01/2023 Policy Number: HUM-0423-032 Page: 28 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.

  • 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.

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    See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

    Bariatric Surgery Effective Date: 01/01/2024 Revision Date: 01/01/2024 Review Date: 03/01/2023 Policy Number: HUM-0423-032 Page: 29 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.

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    See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

    Bariatric Surgery Effective Date: 01/01/2024 Revision Date: 01/01/2024 Review Date: 03/01/2023 Policy Number: HUM-0423-032 Page: 30 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.

  • UpToDate, Inc. Intragastric balloon therapy for weight loss. https://www.uptodate.com. Updated December 2022. Accessed January 24, 2023.

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    • See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.