Bariatric Surgery and Procedures

1 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.

2 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 .. 49 Cholecystectomy, liver Biopsy, Herniorrhaphy, Prophylactic Vena Cava Filter Placement, or Upper Endoscopy .. 54 Medicare Coverage Determinations .. 61 Coding/Billing 62 References .. 67 Related Coverage Resources Gastric Pacing/Gastric Electrical Stimulation (GES) Surgical Treatments for Obstructive Sleep Apnea Panniculectomy and Abdominoplasty Sleep Management Vagus Nerve Stimulation (VNS) INSTRUCTIONS FOR USE The following Coverage Policy applies to health benefit plans administered by Cigna Companies.

3 Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based.

4 For example, a customer s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer s benefit plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation.

5 Each coverage request should be reviewed on its own merits. Medical directors are expected to exercise clinical judgment and Page 2 of 92 Medical Coverage Policy: 0051 have discretion in making individual coverage determinations. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations. Overview This Coverage Policy addresses Bariatric Surgery and Procedures for the treatment of morbid obesity.

6 Coverage Policy Coverage for Bariatric Surgery or revision of a Bariatric surgical procedure varies across plans and may be governed by state mandates. Refer to the customer s benefit plan document for coverage details. This coverage policy statement is organized as follows: 1) Criteria that applies to Adults only 2) Criteria that applies to Adolescents only 3) Criteria that applies to Adults and Adolescents Adults 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.

7 BMI (Body Mass Index) 40 kg/m2 (BMI kg/m2 in Asians- when ethnicity is confirmed by provider attestation) BMI (Body Mass Index) 35 kg/m2 (BMI kg/m2 in Asians- when ethnicity is confirmed by provider attestation) with at least one clinically significant obesity-related comorbidity, including but not limited to the following: o mechanical arthropathy in a weight-bearing joint (symptomatic degenerative joint disease in a weight bearing joint) o diabetes mellitus o poorly controlled hypertension (systolic blood pressure at least 140 mm Hg or diastolic blood pressure 90 mm Hg or greater, despite optimal medical management) o hyperlipidemia o coronary artery disease o lower extremity lymphatic or venous obstruction o obstructive sleep apnea o pulmonary hypertension o evidence of fatty liver disease ( , nonalcoholic fatty liver disease [ nafld ] or nonalcoholic steatohepatitis [NASH]) o gastroesophageal reflux disease (GERD)

8 Refractory to medical therapy A thorough multidisciplinary evaluation within the previous 12 months which includes ALL of the following: a description of the proposed procedure(s) documentation of failure of weight loss by medical management unequivocal clearance for Bariatric Surgery by a mental health provider a nutritional evaluation by a physician, physician assistant, nurse practitioner or registered dietician Page 3 of 92 Medical Coverage Policy: 0051 Bariatric Surgical P rocedures (Adults) When the specific medical necessity criteria noted above for Bariatric Surgery for an adult have been met, ANY of the following open or laparoscopic Bariatric surgical Procedures for the treatment of morbid obesity is considered medically necessary.

9 Procedure Open CPT Codes Laparoscopic CPT Codes Vertical band gastroplasty 43842 43659 Adjustable silicone gastric banding ( , LAP-BAND , REALIZE ) 43843 43770 Sleeve gastrectomy as a stand-alone or staged procedure 43843 43775 Roux-en-Y gastric bypass (roux limb less than 150 cm) 43846 43644 Roux-en-Y gastric bypass (roux limb greater than 150 cm) 43847 43645 Biliopancreatic Diversion with Duodenal Switch (BPD/DS) 43845 43659, 44799 Billiopancreatic Diversion (BPD) without DS 43633 43659, 44799 Single-anastomosis duodenal-ileal bypass with Sleeve gastrectomy (SADI-S) ( Loop duodenal switch) 43999 43659, 44799, 44238, 43775 Adjustment of a silicone gastric banding is considered medically necessary to control the rate of weight loss and/or treat symptoms secondary to gastric restriction following a medically necessary adjustable silicone gastric banding procedure.

10 The following Bariatric surgical Procedures for the treatment of morbid obesity, when performed alone or in conjunction with another Bariatric surgical procedure are considered experimental, investigational or unproven: Procedure CPT Code(s) Band over bypass 43770, 43843, 43999 Band over sleeve 43770, 43843, 43999 Fobi-Pouch (limiting proximal gastric pouch) 43659, 43843, 43999 Gastric electrical stimulation (GES) or gastric pacing 64590 and 43881 OR 64590 and 43647 Intestinal bypass (jejunoileal bypass) 44238, 44799 Intragastric balloon ( , Orbera , ReShape , Obalon) 43999 Laparoscopic greater curvature plication 43659 Mini-gastric bypass/ One Anastomosis Gastric Bypass (OAGB)/Loop gastric bypass 43659, 43843 Endoscopic Bariatric Surgery Procedures , including but not limited to the following.