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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.

Page 4 of 90 Medical Coverage Policy: 0051 . Procedure CPT ® Code(s) 43846 or 43847 and 43843 or 43999 Stomach aspiration therapy (e.g., AspireAssist

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