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Description:
| Morbid obesity is associated with a reduction in life expectancy and significant co-morbid medical conditions. Surgical intervention is considered a form of risk reduction in morbidly obese patients with serious medical problems, although there is no long-term data to support survival benefit. The decision to undergo surgical intervention is shared by the physician and patient and is based on factors such as the patient’s present weight, weight loss history, physical and mental readiness, patient expectations and motivation, all of which are determined by a qualified team of professionals with integrated knowledge of medicine, surgery, psychiatry, nutrition and exercise. |
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Policy:
| The surgical treatment of morbid obesity may be considered MEDICALLY NECESSARY for patients who meet the following criteria:
- The patient must have a Body Mass Index (BMI) of >40. Patients with a BMI of 35-40 will be considered when there is documentation of a co-morbid condition, such as hypertension refractory to standard drug regimens, cardiovascular disease, degenerative joint disease, documented obstructive sleep apnea, severe persistent asthma, or diabetes (See attached Body Mass Index [BMI] table at the end of this policy. This table was adapted from the NIH "Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults").
- The condition of morbid obesity must be of at least two years duration. Because attempts to lose weight over this two-year time period may cause the patient’s BMI to fluctuate around the required levels, the two-year time period will not necessarily start over, or be prolonged, but will be reviewed on a case-by-case basis.
- The patient has participated in at least one medically-supervised attempt to lose weight within the past two years. The medically-supervised weight loss attempt(s) must include six (6) monthly medical visits over six (6) consecutive months with all visits under the direction of a medical doctor (MD or DO), physician's assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS), or a registered dietitian supervised by an MD, DO, PA, NP, or CNS. The patient's participation in a structured weight loss regimen must be documented in the medical record by an attending physician who supervised the patient's progress. A physician's notation, alone, is not sufficient documentation. Documentation should include medical records indicating the patient's adherence to the current nutrition and exercise program and the provider's recommended changes to the nutrition and exercise program throughout the course of the medically-supervised weight loss regimen. Such documentation is necessary to establish the patient's ability to comply with the dietary and lifestyle changes necessary for maintaining weight loss following surgery.
- The patient must be evaluated preoperatively by an eligible licensed mental health provider (i.e., licensed psychologist [Ph.D or M.A], licensed clinical social worker [LICSW], or licensed marriage and family therapist [LMFT]) to ensure the patient’s ability to understand, tolerate and comply with all phases of care and to ensure a commitment to long-term follow-up requirements. The evaluation must also ensure that any psychiatric, chemical dependency, or eating disorder contraindications to the surgery have been ruled out. Documentation of this evaluation must be included in the prior authorization.
- The physician requesting authorization for the surgery must confirm that the patient’s treatment plan includes pre- and post-operative dietary evaluations*
* Pre- and post-operative dietary evaluations are defined as
evaluations conducted by a dietitian/nutritionist.
Surgical Procedures
The following surgical procedures may be MEDICALLY NECESSARY in the treatment of morbid obesity when the previous criteria have been met:
- Open gastric bypass using a Roux-en-Y anastomosis with an alimentary or Roux limb of ≤ 150 cm;
- Laparoscopic gastric bypass using a Roux-en-Y anastomosis;
- Open vertical banded gastroplasty;
- Adjustable gastric banding, consisting of an adjustable external band placed around the stomach (i.e., Lap-Band® and REALIZE Band);
- Open or laparoscopic biliopancreatic bypass (i.e., Scopinaro procedure) with duodenal switch in patients with a BMI ≥ 50)
The following surgical procedures are considered INVESTIGATIVE and NOT MEDICALLY NECESSSARY as a treatment of morbid obesity:
- Laparoscopic vertical banded gastroplasty; and
- Gastric bypass using a Billroth II type of anastomosis, known as the mini-gastric bypass;
- Biliopancreatic bypass (i.e., the Scopinaro procedure) without duodenal switch;
- Open or laparoscopic sleeve gastrectomy, either as the sole procedure or as the first stage in a two-staged procedure:
- Long-limb gastric bypass procedure (i.e., > 150 cm);
- Endoscopic procedures (e.g., insertion of the StomaphyX™ device, sclerosing endotherapy) to treat weight gain after bariatric surgery or to remedy large gastric stoma or large gastric pouches;
- Bariatric surgery (any procedure) solely as a cure for type 2 diabetes mellitus
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 | Re-operation Criteria
Subsequent surgery for morbid obesity is subject to the previous criteria and the patient’s contract benefits. |
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Coverage:
| Prior Authorization: Yes, for all bariatric surgery and revisions / reoperations. Submitted documentation should address the patient selection criteria described above. |
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| Coding: | The following codes are included below for informational purposes only, and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
CPT:
00797 Anesthesia for...gastric restrictive procedure for morbid obesity
43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass & Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
43645 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass & small intestine reconstruction to limit absorption
43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band & subcutaneous port components)
43771 Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric band component only
43772 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric band component only
43773 Laparoscopy, surgical, gastric restrictive procedure; removal & replacement of adjustable gastric band component only
43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric band & subcutaneous port components
43842 Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty
43843 Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty
43845 Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy & ileoileostomy (50-100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal
switch)
43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy
43847 Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption 43848 Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric band (separate procedure)
43886 Gastric restrictive procedure, open; revision of subcutaneous port component only
43887 Gastric restrictive procedure, open; removal of subcutaneous port component only
43888 Gastric restrictive procedure, open; removal & replacement of subcutaneous port component only
HCPCS:
S2083 Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline
ICD-9 Procedure:
43.7 Partial gastrectomy with anastomosis to jejunum
43.89 Other partial gastrectomy; other
44.31 High gastric bypass
44.38 Laparoscopic gastroenterostomy
44.39 Other gastroenterostomy
44.5 Revision of gastric anastomosis
44.68 Laparoscopic gastroplasty
44.69 Other repair of stomach; other
44.95 Laparoscopic gastric restrictive procedure
44.96 Laparoscopic revision of gastric restrictive procedure
44.97 Laparoscopic removal of gastric restrictive device
44.98 Laparoscopic adjustment of size of adjustable gastric restrictive device
44.99 Other operations on stomach; other
45.51 Isolation of segment of small intestine
45.91 Small-to-small intestinal anastomosis
Deleted Codes: S2082, S2085 |
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| Policy History: | Medical and Behavioral Health
Policy Committee Review:
Revised December 10, 2008
Revised May 13, 2009
Medical Policy
Committee Review
Developed December 20, 1985
Revised January 26, 1990
Revised January 3, 1992
Revised December 2, 1992
Revised December 11, 1996
Code Revision February 7, 1997
Revised May 12, 1999
Revised December 10, 2003
Revised May 12, 2004
Revised July 14, 2004
Reviewed September 14, 2005
Revised October 11, 2006
Revised February 14, 2007 (Sleeve gastrectomy)
Revised July 11, 2007
Revised December 12, 2007 (Sclerosing endotherapy)
Revised January 9, 2008 (REALIZE Band)
Medical Policy
Subcommittee Review
Reviewed October 1, 1998
Reviewed December 13, 2000
Reviewed November 14, 2001
Reviewed December 16, 2002 |
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| Cross Reference: | Excision of Redundant Skin, IV-24 |
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