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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.

o coronary artery disease o lower extremity lymphatic or venous obstruction o obstructive sleep apnea o pulmonary hypertension o evidence of fatty liver disease (i.e., nonalcoholic fatty liver disease [NAFLD] or nonalcoholic steatohepatitis [NASH]) o gastroesophageal reflux disease (GERD) refractory to medical therapy

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  Disease, Fatty, Sanh, Liver, Steatohepatitis, Nafld, Nonalcoholic fatty liver disease, Nonalcoholic, Nonalcoholic steatohepatitis, Fatty liver disease

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