Highmark Commercial Medical Policy - Pennsylvania
Medical Policy: G-24-051
Topic: Obesity
Section: Miscellaneous
Effective Date: September 18, 2017
Issue Date: September 18, 2017
Last Reviewed: November 2016

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.

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.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

The following bariatric procedures may be considered medically necessary for the surgical treatment of morbid obesity when ALL of the patient selection criteria are met. Bariatric surgery should be performed in appropriately selected patients by surgeons who are adequately trained and experienced in the specific techniques used and in institutions that support a comprehensive bariatric surgery program, including long-term monitoring and follow-up post-surgery.  

Patient Selection Criteria for Adults

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

Procedure Codes
43644, 43770, 43775, 43843, 43845, 43846


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:

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

Procedure Codes
43644, 43770, 43775, 43843, 43845, 43846


Repeat or Revised Bariatric Surgical Procedures

Surgical repair to correct perioperative or late chronic complications of a bariatric procedure may be considered medically necessary when there is documentation of a surgical complication related to the perioperative or late chronic complications of a bariatric procedure. These include but are not limited to:

Repeat surgical procedures for revision or conversion to another surgical procedure may be considered medically necessary when the initial bariatric surgery was medically necessary (and the individual continues to meet all the medical necessity criteria for bariatric surgery); and when ANY ONE of the following criteria is met:

Inadequate weight loss due to individual noncompliance with postoperative nutrition and exercise recommendations is considered not medically necessary for revision or conversion surgery, and therefore non-covered. 

Individual postoperative noncompliance negates the efficacy of revision or conversion surgery.

Repeat procedures for repair, revision, or conversion to another surgical procedure following a gastric bypass or gastric restrictive procedure are considered not medically necessary when the criteria listed above are not met.

Procedure Codes
43644, 43771, 43772, 43773, 43774, 43775, 43845, 43846, 43848, 43886, 43887, 43888


Gastric stapling and gastric bypass surgery reported for the treatment of "morbid obesity" should be processed under the appropriate procedure codes. 

Itemized charges reported for gastroduodenostomy and/or surgery should be combined with the stapling or bypass surgery. 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. A liver biopsy upper gastrointestinal endoscopy and esophagogastroduodenoscopy (EGD) are considered an inherent part of all bariatric surgical procedures. 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. 

Procedure Codes
10021, 10022, 43235, 43236, 43237, 43238, 43239, 43241, 43253, 43259, 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43843 , 43845, 43846, 43847, 43848, 43886, 43887, 43888, 47000, 47001, 47100, 47379


The following bariatric procedures are considered experimental/investigational, and therefore, non-covered.  There is insufficient evidence in the peer-reviewed published medical literature regarding effectiveness and safety of these procedures. 

Procedure Codes
43645, 43842, 43847, 43999, 0312T, 0313T, 0314T, 0315T, 0316T, 0317T


Refer to medical policy S-96 Laparoscopic Surgery for additional information.

Refer to medical policy S-155 Gastric Electrical Stimulation/Gastric Pacing for additional information.



Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

The following procedures are typically considered inpatient procedures: Bariatric primary: Biliopancreatic Diversion with Duodenal switch, Roux-en-Y Gastric Bypass (RYGB), Sleeve Gastrectomy and Bariatric Revisional Surgery.

The treatment of obesity is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer: If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.