Medical Treatment

Treatment of obesity is excluded from medical coverage.  However, covered services for the medical treatment for morbid obesity 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:

1. Gastric restrictive surgical procedures (e.g., vertical banded gastroplasty, gastric stapling, laparoscopic adjustable gastric banding, mini-gastric bypass, gastric bypass with Roux-en-Y) create a small gastric pouch, resulting in weight loss from early satiety and decreased dietary intake.  The decreased capacity of the stomach reduces the volume of food an individual consumes before feeling full.
2. Malabsorptive surgical procedures (e. g., biliopancreatic diversion, biliopancreatic diversion with duodenal switch, long-limb gastric bypass, intestinal gastric bypass) bypass a section of the small intestines.  Weight loss results from intestinal malabsorption without dietary modification.

The following procedures are covered for the surgical treatment of morbid obesity when all of the patient selection criteria are met.  (Note:  Coverage for the surgical treatment of morbid obesity is determined according to individual or group customer benefits.)

• Laparoscopic adjustable gastric banding using an FDA-approved adjustable gastric band (43770)
  
  Laparoscopic adjustable gastric banding 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.

NOTE:

Currently, the adjustable gastric band is not FDA approved for patients less than 18 years of age. The FDA premarket approval for the LAP-BAND System indicates it is for use only in severely obese adult patients. (The clinical study that was submitted to the FDA for approval of the LAP-BAND was restricted to adults, ages 18–55 years.) 

• Biliopancreatic bypass with duodenal switch (43845) for members with a BMI of 50≥  kg/m2 or greater
  
  The biliopancreatic bypass with duodenal switch is a modification of the biliopancreatic bypass.  The most significant difference from the biliopancreatic bypass to the duodenal switch procedure is utilization of a sleeve gastrectomy of the greater curvature rather than a distal gastrectomy and anastomosis of the ileum to the duodenum instead of the stomach.
  
  
• Roux-en-Y gastric bypass (RY-GBP) {open (43846) or laparoscopic (43644)}

  The open Roux-en-Y gastric bypass is considered the gold standard for bariatric surgery.  A small (30 cc) proximal gastric pouch is constructed which is then divided from the remainder of the stomach just below the cardia with a short (150 cm or less) Roux-en-Y gastrojejunostomy performed between the proximal gastric pouch and a Roux-en-Y jejunal limb.

• Sleeve Gastrectomy (43775)
  
  For the superobese patient with a BMI of ≥ 50 who is 18 years of age or older, sleeve gastrectomy is an eligible procedure as a first stage of a two-stage procedure, or as a sole definitive procedure.
  
  
  A sleeve gastrectomy is an alternative approach to gastrectomy that can be performed on its own, or in combination with malabsorptive procedures (most commonly Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch). In this procedure, the greater curvature of the stomach is resected from the angle of His to the distal antrum, resulting in a stomach remnant shaped like a tube or sleeve. The pyloric sphincter is preserved, resulting in a more physiologic transit of food from the stomach to the duodenum, and avoiding the dumping syndrome (overly rapid transport of food through stomach into intestines) that is seen with distal gastrectomy. This procedure can be performed by an open or laparoscopic technique. Some surgeons have proposed this as the first in a two-stage procedure for very high-risk patients.

• Vertical banded gastroplasty (43842) and gastric stapling (open) ( 43843)
  
  Note: Code 43843 is not limited to gastric stapling.
  
  Vertical banded gastroplasty is a type of gastric restrictive procedure, which consists of constructing a small pouch with a restricted outlet along the lesser curvature of the stomach.  The outlet may be externally reinforced to prevent disruption or dilation.
  
  Gastric stapling is accomplished by stapling the upper stomach to create a small pouch into which food flows after it’s swallowed.  The outlet of this pouch is restricted by a band of synthetic mesh, which slows its emptying, so that the person feels full after only a few bites of food.

Patient Selection Criteria for Adults

1. The patient is morbidly obese;
   
   Morbid obesity is 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 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).
   
   
2. The patient is at least 18 years old; and
   
   
3. The patient has received non-surgical treatment (e.g., dietitian/nutritionist consultation, low calorie diet, exercise program, and behavior modification) and attempts at weight loss have failed.
   
   
4. The patient must participate in and meet the criteria of a structured nutrition and exercise program.  This includes dietitian/nutritionist consultation, low calorie diet, increased physical activity, behavioral modification, and/or pharmacologic therapy, documented in the medical record.  This structured nutrition and exercise program must meet all of the following criteria:
   
   
   • The nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and
   • The nutrition and exercise program(s) must total 6 visits or more during a period of six consecutive months; and
   • The nutritional and exercise program must occur within two years prior to the surgery; and
   • The patient's participation in a structured nutrition and exercise program must be documented in the medical record by an attending physician who supervised the patient's progress.  A physician's summary letter is not sufficient documentation.  Documentation should include medical records of the physician's on-going assessments of the patient's progress throughout the course of the nutrition and exercise program.  For patients who participate in a structured nutrition and exercise program, medical records documenting the patient's participation and progress must be available for review.
     
     
5. The patient must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery.  The patient's medical record documentation should indicate that all psychosocial issues have been identified and addressed.
   
   
6. Patient selection is a critical process requiring psychiatric evaluation and a multidisciplinary team approach.  The member's understanding of the procedure, and ability to participate and comply with life-long follow-up and the life-style changes (e.g., changes in dietary habits, and beginning an exercise program) are necessary to the success of the procedure.

If the patient does not meet all of the patient selection criteria for bariatric surgery, the procedure will be denied as not medically necessary.

Patient Selection Criteria for Adolescents

The eligible bariatric surgical procedures listed above unless otherwise specified are covered for members under the age of 18 years when they meet all of the following patient selection criteria:

1. Attainment or near-attainment of physiologic/skeletal maturity at approximately, age 13 in girls and 15 for boys (The patient has attained Tanner 4 pubertal development and final or near-final adult height (e.g., ≥ 95 %) of adult stature).
   
   
2. The patient is morbidly obese defined as a BMI of > 50 or severely obese defined as a BMI > 40 with serious comorbidities:
   
   

   • Life threatening cardiopulmonary problems such as severe obstructive sleep apnea, Pickwickian syndrome, obesity related cardiomyopathy, pulmonary hypertension, documented coronary artery disease
   • Pseudomotor cerebri
   • Type II Diabetes
     
     
3. The patient has received non-surgical treatment (e.g., dietitian/nutritionist consultation, low calorie diet, exercise program, and behavior modification) and attempts at weight loss have failed.
   
   
4. The patient must participate in and meet the criteria of a structured nutrition and exercise program. This includes dietitian/nutritionist consultation, low calorie diet, increased physical activity, behavioral modification, and/or pharmacologic therapy, documented in the medical record. This structured nutrition and exercise program must meet all of the following criteria:
   
   
   • The nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and
   • The nutrition and exercise program(s) must total 6 visits or more during a period of six consecutive months; and
   • The nutritional and exercise program must occur within two years prior to the surgery; and
   • The patient's participation in a structured nutrition and exercise program must be documented in the medical record by an attending physician who supervised the patient's progress. A physician's summary letter is not sufficient documentation. Documentation should include medical records of the physician's on-going assessments of the patient's progress throughout the course of the nutrition and exercise program. For patients who participate in a structured nutrition and exercise program, medical records documenting the patient's participation and progress must be available for review.
     
     
5. The patient must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery.  The patient's medical record documentation should indicate that all psychosocial issues have been identified and addressed.
   
   
6. The patient must be able to show decisional capacity and maturity in the psychological evaluation and provide informed assent for surgical management.
   
   
7. The patient must be capable and willing to adhere to nutritional guidelines postoperatively.
   
   
8. The patient must have a supportive and committed family environment.
   
   
9. Patient selection is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. The member's understanding of the procedure and ability to participate and comply with life-long follow-up and the life-style changes (e.g., changes in dietary habits, and beginning an exercise program) are necessary to the success of the procedure.

If the patient does not meet all of the patient selection criteria for bariatric surgery, the procedure will be denied as not medically necessary.

Gastric stapling and gastric bypass surgery reported for the treatment of "morbid obesity" should be processed under the appropriate procedure code 43644, 43842, 43843, 43846, or 43848 respectively.  Claims for "vertical banded gastroplasty" should be processed under code 43842.  (See Medical Policy Bulletin S-96 for additional information on laparoscopic surgery.)

In addition, itemized charges reported for gastroduodenostomy and/or surgery should be combined with the stapling, vertical banded gastroplasty or bypass surgery.  The gastrojejunostomy in conjunction with gastric stapling, vertical banded gastroplasty or gastric bypass claim should be processed under the appropriate code 43644, 43842, 43843, 43846, or 43848.  Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day.  When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

A liver biopsy (10021, 10022, 47001, 47100, 47120, 47122, and 47379), upper gastrointestinal endoscopy and esophagogastroduodenoscopy (EGD) (43234-43239, 43241, and 43259) are considered an inherent part of all bariatric surgical procedures (43644, 43645, 43770-43775, 43842-43848, 43886-43888, and S2083).  These services are not eligible for separate payment when reported on the same day as a bariatric surgical procedure.  When a doctor reports a liver biopsy, upper gastrointestinal endoscopy  or EGD with a bariatric surgical procedure, the charges should be combined under the appropriate bariatric surgery procedure code.  A participating, preferred, or network provider cannot bill the member for the liver biopsy, upper gastrointestinal endoscopy, or EGD.  Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day.  When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

Repeat or Revised Bariatric Surgical Procedures (43771-43774, 43848, and 43886-43888)

• Conversion of a gastric restrictive procedure without gastric bypass (e.g., laparoscopic adjustable gastric banding, or vertical banded gastroplasty) to a gastric restrictive procedure with gastric bypass (e.g., for morbid obesity)
  
  
• Revision of a failed gastric restrictive procedure (e.g., restapling of dehisced vertical banded gastroplasty staple line, severe adhesions of the gastric pouch, stenosis of stoma, dilation of stoma)
  
  A Roux-en-Y gastric bypass (43644, 43846) may be considered medically necessary for patients who have not had adequate weight loss (defined as loss of more than 50 percent of excess body weight) from the primary bariatric surgery (e.g., laparoscopic adjustable gastric banding (43770), vertical banded gastroplasty (43842).  Since, maximal weight loss is not typically achieved until 1 to 2 years of the primary bariatric surgery (e.g., laparoscopic adjustable gastric banding, or vertical banded gastroplasty), a Roux-en-Y gastric bypass is considered not medically necessary and not covered if performed within two years of the primary bariatric surgery.  In addition, a Roux-en-Y gastric bypass following laparoscopic adjustable gastric banding or vertical banded gastroplasty is considered not medically necessary and not covered for patients who have been substantially noncompliant with a prescribed nutrition and exercise program following the primary bariatric surgery.  More than one laparoscopic adjustable gastric banding, vertical banded gastroplasty or Roux-en-Y gastric bypass procedure is considered not medically necessary.
  
  Reoperation may be required to either “take-down” or revise the original bariatric procedure.  Surgical revision or reversal (i.e., take-down) is covered for members who have complications from the primary procedure demonstrated by diagnostic study (e.g., obstruction, stricture, dilation of the gastric pouch).  A reoperation or reversal is considered not medically necessary unless the primary bariatric surgery has resulted in complications, and therefore, it is not covered.  (See Medical Policy Bulletin Z-35 for additional information on repeat surgical procedures.)
  
  Codes 43771-43774, 43886-43888 represent open or laparoscopic revisions, repairs or removal of the components of laparoscopic adjustable gastric banding.  These procedures would be indicated if there was a complication (e.g., infection in the area of the subcutaneous port).

Services that do not meet the medical necessity guidelines outlined in this policy will be considered not medically necessary. A participating, preferred or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost.  The member must agree in writing to assume financial responsibility, in advance of receiving the service.  The signed agreement should be maintained in the provider's records.

Endoscopic procedures (43999) (e.g., insertion of the StomaphyX™ device, ROSE procedure) to treat weight gain after bariatric surgery to remedy large gastric stoma or large gastric pouches are considered experimental/investigational. Well-designed large population, multicenter, controlled clinical trials with long-term follow-up are needed. A participating, preferred, or network provider can bill the member for the denied service. The StomaphyX™ device was approved in March 2007 by the FDA through the 510(k) process. It is being used in endoluminal transoral tissue approximation and ligation in the gastrointestinal tract.

The StomaphyX device is also used in the treatment of gastroesophageal reflux disease. See Medical Policy Bulletin S-145 for information on endoscopic/endoluminal gastroplasty or gastroplication with suturing of the esophagogastric junction in the treatment of GERD.

Date Last Reviewed: 05/2010

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 non-covered service.

• Biliopancreatic bypass (the Scopinaro procedure) (43847) or laparoscopic (43645)

The biliopancreatic diversion (BPD) was first reported by Scopinaro, et al, in 1976 as a procedure that combined both gastric restriction and malabsorption.  The technique includes a partial gastrectomy to create a 200-300 cc pouch followed by division and anastomosis of the terminal ileum to the stomach.  The jejunum is totally excluded from digestive continuity with the distal end anastomosed to the terminal ileum, creating a “common channel” of ileum approximately 50 cm from the ileocecal valve.  A high incidence and the severity of complications following BPD have led many surgeons to restrict its use as an operation for the treatment of super obese patients.

Date Last Reviewed:  08/2009

• Long-limb gastric bypass (i.e., > 150cm) (43847) or laparoscopic (43645)

The long-limb gastric bypass differs from the conventional gastric bypass only in the length of defunctionalized jejunum.  The long-limb gastric bypass was designed to induce greater malabsorption by diverting bile and pancreatic secretions distally in the digestive tract.  This was felt to produce a greater malabsorption of fats without the protein malabsorption associated with intestinal bypass.

Date Last Reviewed:  06/2009

• Mini-gastric bypass

A mini-gastric bypass is a variation of the gastric bypass.  Using a laparoscopic approach, the stomach is segmented, similar to a traditional gastric bypass, but instead of creating a Roux-en-Y anastomosis, the jejunum is anastomosed directly to the stomach, similar to a Billroth II procedure.

Date Last Reviewed:  06/2009

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 alternatives, particularly 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). 

For information on gastric electrical stimulation/gastric pacing for treatment of obesity, please refer to Medical Policy Bulletin S-155.

Place of Service:  Outpatient
Laparoscopic adjustable gastric banding is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to:

1. Significant cardiac co-morbidity

• Myocardial infarction
• Coronary artery disease
• Congestive heart failure
• Previous coronary artery bypass graft (CABG) or stent
• Significant valvular disease
• Previous valve repair/replacement
• Abnormal stress test
• Significant arrhythmia requiring postoperative monitoring
• Any patient taking digoxin or plavix

2. Significant pulmonary co-morbidity

• DVT/PE
• Emphysema
• COPD
• Severe restrictive defect
• Significant dyspnea on exertion
• Poorly controlled asthma

3. Poorly controlled diabetes
4. Anticoagulant therapy
5. Known coagulopathy
6. Diabetic patients with BMI > 60

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.

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.

Gastric restrictive procedures, gastric malabsorptive procedures, and combination restrictive and malabsorptive procedures to treat morbid obesity - a condition in which an individual has a Body Mass Index (BMI) of 40 or more, or an individual with a BMI of 35 or more with co-morbidities who has failed conservative treatment; eligible members must be age 18 or over.

NOTE:

Here are some things to keep in mind about surgery for morbid obesity:

• Prior approval is required for outpatient surgery for morbid obesity.
  
  
• Benefits for the surgical treatment of morbid obesity, performed on an inpatient or outpatient basis, are subject to the following pre-surgical requirements:
  • Diagnosis of morbid obesity for a period of 2 years prior to surgery
  • Participation in a medically supervised weight loss program, including nutritional counseling, for at least 3 months prior to the date of surgery. (Note: Benefits are not available for commercial weight loss programs.)
  • Pre-operative nutritional assessment and nutritional counseling about pre- and post-operative nutrition, eating, and exercise
  • Evidence that attempts at weight loss in the 1 year period prior to surgery have been ineffective
  • Psychological assessment of the member’s ability to understand and adhere to the pre- and post-operative program, performed by a psychiatrist, clinical psychologist, psychiatric social worker, or psychiatric nurse
  • Patient has not smoked in the 6 months prior to surgery
  • Patient has not been treated for substance abuse for 1 year prior to surgery
    
    
• Benefits for subsequent surgery for morbid obesity, performed on an inpatient or outpatient basis, are subject to the following additional pre-surgical requirements:
  
  • All criteria listed above for the initial procedure must be met again
  • Previous surgery for morbid obesity was at least 2 years prior to repeat procedure
  • Weight loss from the initial procedure was less than 50% of the member’s excess body weight at the time of the initial procedure
  • Member complied with previously prescribed postoperative nutrition and exercise program
    
    
• Claims for the surgical treatment of morbid obesity must include documentation from the patient’s provider(s) that all pre-surgical requirements have been met
  

02/1993, Obesity
04/2003, Obesity defined
06/2003, Highmark considers laparoscopic adjustable gastric banding investigational
10/2003, Obesity guidelines revised
06/2004, Guidelines on liver biopsy, upper gastrointestinal endoscopy (UGI) and esophagogastroduodenoscopy (EGD) when reported with a bariatric surgical procedure
08/2004, Clarification on patient selection criteria for bariatric surgery
10/2004, Sapala-Wood Micropouch Roux-en-Y gastric bypass
06/2006, Patient selection criteria for bariatric surgery explained
02/2007, Sleeve gastrectomy considered investigational
04/2007, Laparoscopic adjustable gastric banding now eligible for reimbursement
10/2008, StomaphyX not covered
02/2010, Biliopancreatic diversion with duodenal switch now eligible for select criteria
02/2010, Bariatric surgery patient selection criteria explained for adults on structured nutrition and exercise program
02/2010, Certain bariatric surgical procedures eligible for adolescents
08/2010, Place of service designations added to some medical policies
02/2011, Sleeve gastrectomy now eligible for select criteria
02/2011, Place of service designation added to seven medical policies

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Laparoscopic Adjustable Gastric Banding: 1,014 Consecutive Cases, Journal of the American College of Surgeons, Vol., 201, No. 4, 10/2005

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Three-Year Follow-Up Weight Loss Results for Patients Undergoing Laparoscopic Adjustable Gastric Banding at 1 Major University Medical Center: Does the Weight Loss Persist, American Journal of Surgery, Vol. 19, No. 3, 3/2006

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Continued Excellent Results with the Mini-Gastric Bypass: Six-Year Study in 2,410 Patients, Obesity Surgery, Vol. 15, No. 9, 10/2005

Surgical Revision of Loop (Mini) Gastric Bypass Procedure: Multicenter Review of Complications and Conversions to Roux-en-Y Gastric Bypass, Surgery for Obesity and Related Diseases, Vol. 3, No. 1, 01/2007

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