Bariatric Surgery – Community Plan Medical Policy

Bariatric Surgery Page 1 of 64 UnitedHealthcare Community Plan Medical Policy Effective 01/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. UnitedHealthcare Community Plan Medica l Policy Bariatric Surgery Policy Number: Effective Date: January 1, 2021 Instructions for Use Table of Contents Page Application .. 1 Coverage Rationale .. 1 Definitions .. 3 Applicable Codes .. 4 Description of Services .. 5 Clinical Evidence .. 9 Food and Drug Administration .. 51 References .. 52 Policy History/Revision Information .. 63 Instructions for Use .. 64 Application This Medical Policy does not apply to the states listed below; refer to the state-specific Policy /guideline, if noted: State Policy /Guideline Indiana Bariatric Surgery (for Indiana Only) Kentucky Bariatric Surgery (for Kentucky Only) Louisiana Bariatric Surgery (for Louisiana Only) Mississippi Bariatric Surgery (for Mississippi Only) Nebraska Bariatric Surgery (for Nebraska Only) New Jersey Bariatric Surgery (for New Jersey Only) North Carolina Bariatric Surgery (for North Carolina Only) Pennsylvania Bariatric Surgery (for Pennsylvania Only) Tennessee Bariatric Surgery (for Tennessee Only) Coverage Rationale The following Bariatric surgical procedures are proven and medically necessary for treating obesity: Biliopancreatic bypass/biliopancreatic diversion with duodenal switch Gastric bypass (includes roboti)

Gastrointestinal liners (EndoBarrier ®) are investigational, unproven, and not medically necessary for treating obesity due to lack of U.S. Food and Drug Administration (FDA) approval and insufficient evidence of efficacy. Definitions . Adolescent : Individuals 12-21 years of age (Hardin and Hackell [American Academy of Pediatrics], 2017).

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  American, Surgery, Gastrointestinal, Bariatric, Bariatric surgery

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