Highmark Medical Policy Bulletin |
Section: | Miscellaneous |
Number: | G-24 |
Topic: | Obesity |
Effective Date: | July 14, 2003 |
Issued Date: | November 1, 2003 |
Date Last Reviewed: | 05/2003 |
Indications and Limitations of Coverage
Medical Treatment 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 not covered. Surgical Treatment 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 experimental/investigational, and therefore, it is not covered. 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. Description 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. |
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43842 | 43843 | 43846 | 43847 | 43848 |
Traditional (UCR/Fee Schedule) Guidelines
Under the Federal Employee 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 / Wraparound / PPO / Major Medical Guidelines
Comprehensive and Wraparound |
Any reference in this bulletin to non-billable services by a network provider may not be applicable to Major Medical.
Managed Care (HMO/POS) Guidelines
PRN References |
National Heart, Lung, and Blood Institute, Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight Obesity in Adults, National Institute of Health 1998 |
[Version 002 of G-24] |
[Version 001 of G-24] |