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Bariatric Surgery and Procedures - Cigna

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 .. 6 General Background .. 7 Bariatric Surgical Procedures .. 14 Other Bariatric Surgical Procedures .. 23 Reoperation/Revisional Bariatric Surgery .. 48 Bariatric Surgery for the Treatment of Other Conditions.

Bariatric surgery for the treatment of morbid obesity in an adult (age ≥ 18 years) using a covered procedure outlined below is considered medically necessary when ALL of the following criteria are met: • EITHER of the following: BMI (Body Mass Index) ≥ 40 kg/m2 (BMI ≥ 37.5 kg/m2 in Asians- when ethnicity is confirmed by

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