Highmark Medical Policy Bulletin |
Section: | Miscellaneous |
Number: | G-24 |
Topic: | Obesity |
Effective Date: | June 27, 2005 |
Issued Date: | June 27, 2005 |
Date Last Reviewed: |
Indications and Limitations of Coverage
Medical Treatment
Treatment of obesity (278.00) is excluded from medical coverage. However, covered services for the medical treatment for morbid obesity (278.01) are eligible for reimbursement. Coverage for the medical treatment of morbid obesity is determined according to individual or group customer benefits. Surgical Treatment There are a variety of surgeries intended for the treatment of morbid obesity. All procedures fall into one of these two categories:
The following procedures are covered for the surgical treatment of morbid obesity when all of the patient selection criteria are met.
The following procedures are considered experimental/investigational, and therefore, they are not covered. A participating, preferred or network provider can bill the member for the denied service.
There is a lack of peer reviewed medical literature that contains comparative data that demonstrates the above mentioned procedures are equivalent to or offer any advantage over the accepted standard of vertical-banded gastroplasty or Roux-en-Y gastric bypass. Intestinal bypass The intestinal (e.g., jejunoileal) bypass is created by dividing the small bowel 30 cm distal to the ligament of Treitz. The proximal cut end of the small bowel is anastomosed to the terminal ileum 50 cm proximal to the ileocecal valve. The rest of the small bowel remains a blind loop. When intestinal bypass surgery is reported, the claim should be processed in accordance with Medical Policy Bulletin G-21 (procedures of questionable current usefulness). 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. |
|
10021 | 10022 | 43234 | 43235 | 43236 | 43237 |
43238 | 43239 | 43241 | 43259 | 43644 | 43645 |
43842 | 43843 | 43845 | 43846 | 43847 | 43848 |
47001 | 47100 | 47120 | 47122 | 47379 | S2082 |
S2083 |
Traditional (UCR/Fee Schedule) Guidelines
This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the FEP contract and the Service Benefit Plan Brochure that is in effect at the time services are rendered. |
Comprehensive / Wraparound / PPO / Major Medical Guidelines
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). |
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 02/1993, Obesity 04/2003, Obesity defined |
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 Medical Policy 7.01.47, Surgery for Morbid Obesity, 11/2004 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 Laparoscopic Surgery for Morbid Obesity, Surgical Clinics of North American, Volume 81, No. 5, 10/2001 Gastrointestinal Surgery for Severe Obesity, National Institutes of Health, Consensus Development Conference Statement, 03/1991 Malabsorptive Obesity Surgery, Surgical Clinics of North America, Volume 81, No. 5, 10/2001 Morbid Obesity: the Value of Surgical Intervention, Clinics in Family Practice, Volume 4, No. 2, 06/2002 Obesity and Its Surgical Management, American Journal of Surgery, Volume 184, No. 2, 08/2002 Medical and Surgical Options in the Treatment of Severe Obesity, American Journal of Surgery, Volume 184, No. 6B, 12/2002 Bariatric Surgery: Creating New Challenges for the Endoscopist, Gastrointestinal Endoscopy, Volume 57, No. 1, 01/2003 Management of the Bariatric Surgery Patient, Endocrinology and Metabolism Clinics, Volume 32, No. 2, 06/2003 The micropouch gastric bypass: technical considerations in primary and revisionary operations, Obesity Surgery, Volume 11, No.1, 02/2001 Laparoscopic Adjustable Gastric Band, Surgical Clinics of North America, Volume 85, No. 1, 02/2005 Weight Loss and Improvement of Obesity-Related Illness in 500 U.S. Patients following Laparoscopic Adjustable Gastric Banding Procedure, American Journal of Surgery, Volume 189, No. 1, 01/2005 Optimal Management of the Morbidly Obese Patient-SAGES Appropriateness Conference Statement, Surgical Endoscopy, Volume 18, No. 7, 07/2004 Controversies in Bariatric Surgery: Evidence-Based Discussions on Laparoscopic Adjustable Gastric Banding, Journal Gastrointestinal Surgery, Volume 8, No. 4, 05/2004 |
[Version 009 of G-24] |
[Version 008 of G-24] |
[Version 007 of G-24] |
[Version 006 of G-24] |
[Version 005 of G-24] |
[Version 004 of G-24] |
[Version 003 of G-24] |
[Version 002 of G-24] |
[Version 001 of G-24] |