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Bariatric Surgery and Procedures

Medical Coverage Policy Page 1 of 92 Medical Coverage Policy: 0051 Effective Date .. 7/15/2022 Next Review Date .. 7/15/2023 Coverage Policy Number .. 0051 Bariatric Surgery and Procedures Table of Contents Overview .. 2 Coverage Policy .. 2 Adults .. 2 Bariatric Surgical Procedures (Adults) .. 3 Reoperation and Revisional Bariatric Surgery (Adults) .. 4 Adolescents .. 5 Bariatric Surgical Procedures (Adolescents) .. 5 Reoperation and Revisional Bariatric Surgery (Adolescents) .. 6 Adults and 6 Bariatric Surgery for the Treatment of Other Conditions .. 6 Cholecystectomy, Liver Biopsy, Herniorrhaphy, Prophylactic Vena Cava Filter Placement, or Upper Endoscopy.

Gastric electrical stimulation (GES) or gastric pacing 64590 and 43881 OR . 64590 and 43647 Gastroplasty (stomach stapling) 43659, 43843 Intestinal bypass (jejunoileal bypass) 44238, 44799 Intragastric balloon (e.g., Orbera™, ReShape™, Obalon) 43999 Laparoscopic greater curvature plication 43659 Loop gastric bypass 43659, 43843

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  Bypass, Gastric, Gastric bypass

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