Bariatric Surgery MM /11/2001. HMO; PPO; QUEST 05/01/2012 Section: Surgery Place(s) of Service: Outpatient; Inpatient

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1 Bariatric Surgery Policy Number: Original Effective Date: MM /11/2001 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 05/01/2012 Section: Surgery Place(s) of Service: Outpatient; Inpatient I. Description Surgery for morbid obesity, termed bariatric surgery, falls into two general categories: 1) gastricrestrictive procedures that create a small gastric pouch, resulting in weight loss by producing early satiety and thus decreasing dietary intake; and 2) malabsorptive procedures, which produce weight loss due to malabsorption by altering the normal transit of ingested food through the gastrointestinal tract. Some bariatric procedures may include both a restrictive and a malabsorptive component. Morbid obesity is defined as a body mass index (BMI) greater than 40 kg/m2 or a BMI greater than 35 kg/m2 with associated complications including, but not limited to, diabetes, hypertension, or obstructive sleep apnea. Morbid obesity results in a very high risk for weight-related complications, such as diabetes, hypertension, obstructive sleep apnea, and various types of cancers (for men: colon, rectum, and prostate; for women: breast, uterus, and ovaries), and a shortened life span. A 1991 National Institutes of Health (NIH) Consensus Conference defined surgical candidates as those patients with a BMI of greater than 40 kg/m2, or greater than 35 kg/m2 in conjunction with severe comorbidities such as cardiopulmonary complications or severe diabetes. Resolution (cure) or improvement of type 2 diabetes mellitus after bariatric surgery and observations that glycemic control may improve immediately after surgery, before a significant amount of weight is lost, have promoted interest in a surgical approach to treatment of type 2 diabetes. The various surgical procedures have different effects, and gastrointestinal rearrangement seems to confer additional anti-diabetic benefits independent of weight loss and caloric restriction. The precise mechanisms are not clear, and multiple mechanisms may be involved. Gastrointestinal peptides, glucagon-like peptide-1 (1GLP-1), glucose -dependent insulinotropic peptide (GIP), and peptide YY (PYY) are secreted in response to contact with unabsorbed nutrients and by vagally mediated parasympathetic neural mechanisms. GLP-1 is secreted by the L cells of the distal ileum in

2 Bariatric Surgery 2 response to ingested nutrients and acts on pancreatic islets to augment glucose-dependent insulin secretion. It also slows gastric emptying, which delays digestion, blunts postprandial glycemia, and acts on the central nervous system to induce satiety and decrease food intake. Other effects may improve insulin sensitivity. GIP acts on pancreatic beta cells to increase insulin secretion through the same mechanisms as GLP-1, although it is less potent. PYY is also secreted by the L cells of the distal intestine and increases satiety and delays gastric emptying. II. Criteria/Guidelines HMSA strongly recommends that prior to considering bariatric surgery, patients be evaluated by a multi-disciplinary clinical team (e.g., endocrinologists, psychiatrists, surgeons, dieticians, nurse practitioners) at a Medicare defined Center of Excellence or at a program that offers comprehensive weight management services. The program should contain the following services and be offered at the same location as the proposed surgical procedure to insure continuity of care: Nutrition counseling Weight-loss program Exercise guidance and support Education about lifestyle changes Preparation and follow up for surgery Support groups for patients before and after surgery A. Surgery for morbid obesity is covered (subject to Limitations/Exclusions and Administrative Guidelines) for members when the following criteria are met: 1. The patient is morbidly obese, defined as either of the following: a. Persistent and uncontrollable weight gain that constitutes a present or potential threat to life; i. Weight that is at least 100 pounds over or twice the ideal weight as described in the Metropolitan Life tables; or ii. A BMI greater than 40 kg/m²; or b. BMI of between 35 and 40 kg/m² with one of the following high-risk comorbidities: i. Severe sleep apnea (defined as repeated hypoxia with oxygen saturation less than 80% on sleep study; or documented pulmonary hypertension on echocardiogram or right heart catheterization; or sleep apnea induced right heart failure requiring hospitalization). ii. Pickwickian syndrome iii. Obesity-related cardiomyopathy iv. Diabetes mellitus with evaluation and recommendation for surgery by a multidisciplinary team with expertise in weight, metabolic, and diabetic management and which is part of a comprehensive weight management program associated with the facility where the surgery will be performed.

3 Bariatric Surgery 3 2. The surgery is intended to achieve one of two results: a. Alteration of the mechanics of food absorption; or b. Alteration in the volume of food ingested. 3. There is documentation that the patient's efforts to lose weight have not been successful. B. Revisions, replacements, and re-dos of bariatric procedures are covered (subject to Limitations/Exclusions and Administrative Guidelines) if the patient met policy criteria at the time of the initial procedure, and there is documentation of a medically significant complication or failure. III. Limitations/Exclusions A. Lap band procedures must be performed in the outpatient setting unless the physician is recommending the procedure be done in an inpatient setting. When requesting precertification, the physician should outline concerns about the member's comorbidities, complex problems, age considerations, etc. B. Polysomnography performed as part of the routine evaluation of patients prior to bariatric surgery is not covered as it is not known to be effective in improving health outcomes. Please see Polysomnography Sleep Studies policy II.A.4 for coverage criteria. IV. Administrative Guidelines Precertification is required. To precertify for procedure and place of treatment, please complete HMSA's Precertification Request and mail or fax the form as indicated. Click for Metropolitan Life Tables CPT Codes Description Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Rouxen-Y gastroenterostomy (roux limb 150 cm or less) with gastric bypass and small intestine reconstruction to limit absorption Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g. gastric band and subcutaneous port components) revision of adjustable gastric restrictive device component only removal of adjustable gastric restrictive device component only removal and replacement of adjustable gastric restrictive device component only removal of adjustable gastric restrictive device and subcutaneous port components

4 Bariatric Surgery longitudinal gastrectomy (i.e., sleeve gastrectomy) Gastric restrictive procedure, without gastric bypass for morbid obesity; verticalbanded gastroplasty other than vertical-banded gastroplasty Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy with small intestine reconstruction to limit absorption Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) Gastric restrictive procedure, open; revision of subcutaneous port component only removal of subcutaneous port component only removal and replacement of subcutaneous port component only Unlisted procedure, stomach HCPCS S2083 V. Important Reminder Description Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline The purpose of this Medical Policy is to provide a guide to coverage. This Medical Policy is not intended to dictate to providers how to practice medicine. Nothing in this Medical Policy is intended to discourage or prohibit providing other medical advice or treatment deemed appropriate by the treating physician. Benefit determinations are subject to applicable member contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control. This Medical Policy has been developed through consideration of the medical necessity criteria under Hawaii s Patients Bill of Rights and Responsibilities Act (Hawaii Revised Statutes 432E-1.4), generally accepted standards of medical practice and review of medical literature and government approval status. HMSA has determined that services not covered under this Medical Policy will not be medically necessary under Hawaii law in most cases. If a treating physician disagrees with HMSA s determination as to medical necessity in a given case, the physician may request that

5 Bariatric Surgery 5 HMSA reconsider the application of the medical necessity criteria to the case at issue in light of any supporting documentation. VI. References 1. American Gastroenterological Association. Medical position statement on obesity. Gastroenterology. Sept. 2002; 123(3): American Society for Metabolic and Bariatric Surgery. Updated position statement on sleeve gastrectomy as a bariatric procedure. Draft Revised; October 14, Medical Policy Reference Manual. Blue Cross and Blue Shield Association. Surgery for morbid obesity. Policy # ; May Blue Cross and Blue Shield Association. Technology Evaluation Committee. Laparoscopic Adjustable Gastric Banding for Morbid Obesity. February NIH Consensus Development Conference Statement. Gastrointestinal surgery for morbid obesity. March 1991; 9: The American Society for Metabolic and Bariatric Surgery. Updated position statement on sleeve gastrectomy as a bariatric procedure. Revised Surgery for Obesity and Related Diseases Jan-Feb 6(1):1-5. Position Statement.