Obesity is an increase in body weight beyond the limitation of skeletal and physical requirements, as a result of excessive accumulation of fat in the body. In general, 20% to 30% above "ideal" bodyweight, according to standard life insurance tables, constitutes obesity. Morbid obesity is further defined as a condition of consistent and uncontrollable weight gain that is characterized by a weight which is at least 100 lbs. or 100% over ideal weight or a body mass index (BMI) of at least 40 or a BMI of 35 with comorbidities (e.g., hypertension, cardiovascular heart disease, dyslipidemia, diabetes mellitus type II, sleep apnea).

Body mass index (BMI) is a method used to quantitatively evaluate body fat by reflecting the presence of excess adipose tissue. BMI is calculated by dividing measured bodyweight in kilograms by the patient's height in meters squared. The normal BMI is 20-25 kg/meters squared.

Medical Treatment
Obesity itself is not considered an illness or disease. Services performed solely for the diagnosis or treatment of this condition are non-covered.

Any weight-reduction services performed in the treatment of concomitant medical conditions (e.g., hypertension), even when those medical conditions could be improved through weight loss, are also non-covered.

Surgical Treatment
Gastric stapling, "vertical banded gastroplasty", and gastric bypass surgery reported for the treatment of "Morbid Obesity" are eligible. Claims for laparoscopic Roux-en-Y gastric bypass should be reported under code 43659. (See MPB S-96 for additional information on laparoscopic surgery.)

In addition, itemized charges reported for gastroduodenostomy and/or gastrojejunostomy in conjunction with gastric stapling or gastric bypass surgery should be combined with the stapling or bypass surgery.

Laparoscopic adjustable gastric banding (e.g., the Lap-Band system) involves creating a gastric pouch by placing a gastric band around the exterior of the stomach.  The band is attached to a reservoir that is implanted subcutaneously in the abdominal fascia in the patient’s upper abdomen.  Injecting the reservoir with saline will alter the diameter of the gastric band.  This limits food consumption and creates an earlier feeling of fullness.  Subsequent adjustments can be made either to tighten or loosen the band to meet individual patient needs.

There is a lack of peer reviewed medical literature that contains comparative data that demonstrates the Lap-Band system is equivalent or offers any advantage over the accepted standard of vertical-banded gastroplasty or gastric bypass.  Additionally, further studies are needed to determine the long-term efficacy of this procedure.  Laparoscopic adjustable gastric banding is considered investigational/experimental, and therefore, it is noncovered.  A participating, preferred or network provider can bill the member for the denied service.

Refer to Medical Policy Bulletin G-21 (procedures of questionable current usefulness) for intestinal bypass surgery.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Under the Federal Employee's Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious life-threatening condition and when medically necessary and appropriate for the patient's condition. Laparoscopic adjustable gastric banding (the Lap-Band system) (43659) is considered an eligible service when determined medically necessary based on the patient's condition.

Comprehensive and Wraparound

Payment should not be made for medical services performed for the evaluation and treatment of obesity alone unless such services are a necessary treatment of a disease or condition aggravated by obesity (e.g., cardiac and respiratory diseases, diabetes, and hypertension).

PRN References

02/1993, Obesity
04/2003, Obesity defined
06/2003, Highmark considers laparoscopic adjustable gastric banding investigational

National Heart, Lung, and Blood Institute, Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight Obesity in Adults, National Institute of Health 1998

Laparoscopic Adjustable Silicone Gastric Banding, Surgical Clinics of North America, Volume 81, No. 5, 10/2001

National Blue Cross Blue Shield Association Medial Policy 7.01.47, Surgery for Morbid Obesity, 2/2002

Overview of Bariatric Surgery, Journal of American College of Surgeons, Volume 194, No. 3, 03/2002

Evidence-Based Medicine: Open and Laparoscopic Bariatric Surgery, Surgical Endoscopy, Volume 16, No. 5, 05/2002

Laparoscopic Adjustable Gastric Banding at a U.S. Center with up to 3-Year Follow-Up, Obesity Surgery, Volume 12, No. 3, 06/2002

Long-Term Data Indicate a Progressive Loss in Efficacy of Adjustable Silicone Gastric Banding for the Surgical Treatment of Morbid Obesity, Surgery, Volume 132, No. 4, 10/2002