Medical Review Criteria Bariatric Surgeries

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1 Medical Review Criteria Bariatric Surgeries Subject: Bariatric Surgeries Backgrund: Mrbid besity (als called clinically severe besity) is a serius health cnditin that can interfere with basic physical functins such as breathing r walking, and reduce life expectancy. Individuals wh are mrbidly bese are at greater risk fr serius medical cmplicatins including hypertensin, crnary artery disease, type 2 diabetes mellitus, sleep apnea, gastresphageal reflux disease and stearthritis. While the immediate cause f besity is calric intake that persistently exceeds calric utput, a limited number f cases may als be caused by illnesses such as hypthyridism, Cushing's disease, and hypthalamic lesins. Nnsurgical strategies fr achieving weight lss and weight maintenance (e.g., calric restrictin, increased physical activity, behaviral mdificatin) are recmmended fr mst verweight and bese persns. Bariatric (weight lss) surgery is a majr surgical interventin, usually cnsidered as a resrt fr individuals with severe besity wh have nt achieved permanent weight lss despite attempts using ther frms f medical management (e.g., behavir change, increased physical activity, drug therapy). Bariatric surgery is indicated fr adults and adlescents wh have cmpleted bne grwth, and are mrbidly bese. Bariatric surgery prcedures mdify the anatmy f the gastrintestinal tract and cause weight lss by restricting the amunt f fd the stmach can hld, causing malabsrptin f nutrients. Bariatric prcedures can ften cause hrmnal and metablic changes that result frm gastric and intestinal surgery. The mst cmmn bariatric surgery prcedures are gastric bypass, sleeve gastrectmy, adjustable gastric band, and bilipancreatic diversin with dudenal switch. Restrictive prcedures (e.g., adjustable gastric banding, vertical banded gastrplasty) cause weight lss by limiting the stmach s capacity and slwing the flw f ingested nutrients. Expected weight lss with restrictive prcedures is apprximately 50-70% f the individual's pre-surgery bdy weight. The fllwing are descriptins f bariatric surgery prcedures: 1. Adjustable Gastric Banding (AGB) AGB achieves weight lss thrugh gastric restrictin nly. An inflatable dughnut-shaped balln band creates a gastric puch f apprximately 15 t 30 cc s in the uppermst prtin f the stmach. The diameter f the band can be adjusted in the clinic by adding r remving saline thrugh a prt that is psitined beneath the skin and allws the size f the gastric utlet t be mdified. AGB prcedures are laparscpic nly. 2. Bilipancreatic Diversin with Dudenal Switch (BPD/DS) BPD/DS partially resects the stmach and achieves weight lss thrugh gastric restrictin and malabsrptin. Meal intake des nt need t be restricted radically and patients eat relatively nrmal-sized meals, as the prximal areas f the small intestine (e.g. dudenum and jejunum) are bypassed and substantial malabsrptin ccurs. Partial BPD/DS invlves resectin f the greater curvature f the stmach. It preserves the pylric sphincter and transects the dudenum abve the ampulla f Vater with a duden-ileal anastmsis and a lwer ileileal anastmsis. BPD/DS can be pen r laparscpic. 3. Rux-en-Y Gastric Bypass (RYGBP) RYGBP reduces the stmach t a small gastric puch (30 cc), which results in feelings f satiety fllwing smaller meals. This prcedure achieves weight lss thrugh gastric Bariatric Surgeries Page 1 f 9 HPHC plicies are based n medical science, and written fr the majrity f peple with a given cnditin. Cverage described in this plicy is standard under mst HPHC plans. Specific benefits may vary by prduct and/r emplyer grup. Please reference apprpriate member materials (e.g., Benefit Handbk, Certificate f Cverage) fr member-specific benefit infrmatin.

2 restrictin and malabsrptin. The small gastric puch is jined t a segment f the jejunum, bypassing the dudenum and very prximal small intestine, ultimately reducing absrptin. RYGBP can be pen r laparscpic. 4. Sleeve Gastrectmy The greater curvature f the stmach is resected frm the angle f His t the distal antrum, resulting in a tube r sleeve shaped stmach. The pylric sphincter is preserved, resulting in a mre physilgic transit f fd frm the stmach t the dudenum. This prevents the dumping syndrme, which ccurs when there is an verly rapid transprt f fd thrugh the stmach int the intestines. 5. Vertical Gastric Banding (VGB) VGB achieves weight lss by gastric restrictin nly. The upper part f the stmach is stapled, which creates a narrw gastric inlet r puch that remains cnnected with the remainder f the stmach. A nn-adjustable band is placed arund the inlet t prevent future enlargement f the pening. This creates a sense f fullness after eating smaller meals. Weight lss frm this prcedure slely depends n eating less. VGB prcedures are essentially n lnger perfrmed. Cntraindicatins fr bariatric surgeries include cardiac cmplicatins, significant respiratry dysfunctin, nncmpliance with medical treatment, psychlgical disrders that a psychlgist/psychiatrist determines are likely t exacerbate r interfere with lng-term management, significant eating disrders, and severe hiatal hernia/gastresphageal reflux. Authrizatin: Prir authrizatin is required fr bariatric surgeries prvided t members enrlled in cmmercial (HMO, POS, PPO) prducts. Plicy and Cverage Criteria: Weight Lss Surgery Centers f Excellence Harvard Pilgrim Health Care (HPHC) has designated selected in-netwrk facilities as Weight Lss Surgery Centers f Excellence (COE); these facilities prvide access t integrated prgrams fcused n patient health, safety and crss-functinal team supprt, and have met stringent quality criteria established by the American Cllege f Surgens and/r the American Sciety fr Metablic and Bariatric Surgery. A list f designated Weight Lss Surgery Centers f Excellence is published n HPHC s public web site. T ensure quality f care, HMO members shuld be directed t a designated Weight Lss Surgery Center f Excellence. Fr POS and PPO members, medically necessary prcedures perfrmed at designated Centers f Excellence facilities are cvered at in-netwrk cst; prcedures perfrmed at nn-coe facilities may be cvered at ut-f-netwrk benefits levels. Initial Prcedures: Harvard Pilgrim Health Care (HPHC) cnsiders bariatric surgeries as medically necessary fr adults and adlescents ver 15 years f age when ALL f the fllwing criteria and all-age specific criteria are met: A. The bariatric surgen has determined the member is an apprpriate candidate fr ONE f the fllwing prcedures: i. Sleeve Gastrectmy ii. Shrt Limb Gastric Bypass/Rux-en-Y (RYGB)- Rux Limb, 150 cm r less Bariatric Surgeries Page 2 f 9 HPHC plicies are based n medical science, and written fr the majrity f peple with a given cnditin. Cverage described in this plicy is standard under mst HPHC plans. Specific benefits may vary by prduct and/r emplyer grup. Please reference apprpriate member materials (e.g., Benefit Handbk, Certificate f Cverage) fr member-specific benefit infrmatin.

3 iii. Adjustable Silicne Gastric Banding (e.g., LAP-BAND, REALIZE Adjustable Gastric Band) iv. Bilipancreatic diversin with dudenal switch (BPD/DS) B. All f the fllwing age-specific criteria are met: i. Adults: Medical recrd dcumentatin cnfirms EITHER a r b belw: a. Bdy Mass Index (BMI) f 40 r mre; OR b. BMI abve 35 AND any f the fllwing high-risk cmrbid cnditins: Type II Diabetes Obstructive Sleep Apnea (OSA) Crnary artery disease Significant besity-related cardipulmnary cnditins (e.g., Hypventilatin Syndrme, Cardimypathy, Pulmnary Hypertensin) Pseudtumr cerebri (diagnsis cnfirmed, and treatment plan supprted by neurlgist) Pickwickian Syndrme Severe, weight-bearing back r jint disease evaluated by an rthpedic r neursurgen Severe arthrpathy f spine and/r weight-bearing jints (when besity prhibits apprpriate surgical management f jint dysfunctin treatable but fr the besity) Hypertensin requiring pharmaclgical treatment (i.e., bld pressure 140 mmhg systlic and/r 90 mmhg diastlic despite medical treatment) Obesity induced cardimypathy Obesity-related hypventilatin The medical cnditins need nt be immediately life-threatening, but must be f sufficient severity as t pse cnsiderable shrt-r lng-term risk t functin and/r survival, and must nt be trivial r easily cntrlled with nn-invasive interventin (e.g., medicatin). Cnsideratin f the risk-benefit fr each individual patient must be used t determine that surgery is the best ptin fr treatment fr the individual patient, and n cntraindicatins t bariatric surgery may exist. ii. Adlescents: Bariatric surgery fr mrbid besity is cnsidered medically necessary fr adlescents between years f age when medical recrd dcumentatin cnfirms the belw criteria: a. Member has attained (r nearly attained) physilgical and skeletal maturity; b. The individual has adequate cgnitive, scial, and emtinal develpment t supprt his/her independent rle in the decisin-making prcess; c. Member has adequate family/scial supprt t ensure cmpliance with lng-term fllwup and supprt a successful lng-term utcme d. EITHER 1 r 2 belw: 1. Bdy Mass Index (BMI) f 40 r mre AND any f the fllwing high-risk cmrbid cnditins: Type II Diabetes Hypertensin requiring pharmaclgical treatment Obstructive Sleep Apnea (OSA) Crnary artery disease Pseudtumr cerebri (diagnsis cnfirmed and treatment plan supprted by neurlgist) 2. BMI f 50 r mre AND any f the fllwing less serius c-mrbidities: Dyslipidemias Bariatric Surgeries Page 3 f 9 HPHC plicies are based n medical science, and written fr the majrity f peple with a given cnditin. Cverage described in this plicy is standard under mst HPHC plans. Specific benefits may vary by prduct and/r emplyer grup. Please reference apprpriate member materials (e.g., Benefit Handbk, Certificate f Cverage) fr member-specific benefit infrmatin.

4 Gastresphageal reflux disease Hypertensin Insulin resistance Intertriginus sft-tissue infectins Nnalchlic steathepatitis Stress urinary incntinence Venus stasis disease Weight-related arthrpathies that impair physical activity The medical cnditins need nt be immediately life-threatening, but must be f sufficient severity as t pse cnsiderable shrt-r lng-term risk t functin and/r survival, and must nt be trivial r easily cntrlled with nn-invasive interventin (e.g., medicatin). Cnsideratin f the risk-benefit fr each individual patient must be used t determine that surgery is the best ptin fr treatment fr the individual patient, and n cntraindicatins t bariatric surgery may exist. C. The member is mtivated t achieve substantial weight lss, is a gd candidate fr the prcedure and lng-term fllw-up, and is well-infrmed abut ptential perative risks, realistic expectatins f surgery, and the need fr lifelng medical fllw up D. Member des nt have ANY f the fllwing cntraindicatins: i. Cardiac cmplicatins (prhibitive periperative risk f cardiac cmplicatins due t cardiac ischemia r mycardial dysfunctin) ii. Severe chrnic bstructive pulmnary disease (COPD) r respiratry dysfunctin iii. Failure t cease tbacc use iv. Histry f significant eating disrders v. Dcumented hepatic disease with inflammatin vi. Prtal hypertensin vii. viii. Ascites Behaviral health cnditin that imparts significant risk f psychlgical/psychiatric decmpensatin r is expected t interfere with lng-term pstperative management. Nte: A histry r presence f mild, uncmplicated, and adequately treated depressin due t besity is nt nrmally cnsidered an abslute cntraindicatin t bariatric surgery. Requests fr bariatric surgery fr patients with cmpensated cirrhsis and mild prtal hypertensin may be apprved n a case-by-case basis. Medical recrd dcumentatin must cnfirm that lcatin and severity f the varices will nt adversely impact likelihd that the member can reasnably be expected t benefit frm the requested prcedure (e.g., sleeve gastrectmy in a patient with stable gastric varies lcated in the fundus). E. In additin, all cvered prcedures must be prvided as part f a cmprehensive multidisciplinary prgram that includes a cmprehensive pre-perative evaluatin (including medical, nutritinal and behaviral health assessment), and apprpriate pst-perative fllw-up including nutritinal and exercise cunseling. Requests fr bariatric surgeries must include medical recrd dcumentatin that cntains ALL the fllwing: i. Assessment and histry f repeated attempts t lse weight (with failure t achieve sustained weight lss) thrugh established nn-surgical weight lss prgrams and/r clinician supervised appraches t lng-term weight lss (e.g., diet/nutritin regimens, behaviral mdificatin, exercise, and/r pharmaclgic agents); AND ii. Behaviral health histry indicating n issues (e.g., active substance abuse, untreated majr depressin r anxiety, ther serius psychlgical disrders) that culd reasnably be expected Bariatric Surgeries Page 4 f 9 HPHC plicies are based n medical science, and written fr the majrity f peple with a given cnditin. Cverage described in this plicy is standard under mst HPHC plans. Specific benefits may vary by prduct and/r emplyer grup. Please reference apprpriate member materials (e.g., Benefit Handbk, Certificate f Cverage) fr member-specific benefit infrmatin.

5 iii. t cmplicate the recuperative prcess r member s cmpliance with diet and pst-surgery fllw-up; AND Evaluatin f member s ability t incrprate nutritinal and behaviral changes (i.e. exercise prgrams based n the individual s capability) befre and after bariatric surgery. Repeat Prcedures: Repeat/Revisin prcedures after bariatric surgery may be authrized fr eligible members ver 15 years f age when cmplicatins are assciated with the initial prcedure that was cnsidered medically necessary. Medical recrd dcumentatin must als cnfirm ANY f the fllwing: Individual s physician requires remval f a gastric band as medically necessary, OR Member requires replacement f an adjustable band due t cmplicatins (e.g., prt leakage, slippage) that cannt be crrected with band manipulatin r adjustments, OR Individual has a symptmatic anatmic abnrmality resulting frm the prir bariatric prcedure (e.g., bstructin, stricture, band ersin, anastmtic stensis r ulcer), and surgery is necessary t crrect cmplicatins necessary t reslve symptms, OR Member failed gastric bypass surgery, due t dilatin f the gastric puch, dilatin f the gastrjejunstmy anastamsis. Member must have remained cmpliant with prescribed nutritin and exercise prgrams and the primary prcedure must have been successful in inducing weight lss prir t the puch/anastamtic dilatin, OR Member has failed t lse at least 50% f excess weight within 2 years f authrized bariatric surgery despite cmpliance with prescribed nutritin and exercise prgrams. (All ther requirements fr cverage f bariatric surgery must be met.) Exclusins: Harvard Pilgrim Health Care (HPHC) des nt cver bariatric surgeries when criteria abve are nt met. In additin, HPHC des nt cver: Repeat r revisinal prcedures when member has nt remained cmpliant t prescribed nutritinal and exercise prgrams Adults and adlescents with Bdy Mass Index (BMI) less than 35 Rux-en-Y gastric bypass as treatment fr gastresphageal reflux in nn-bese persns Open adjustable gastric banding Open sleeve gastrectmy Open r laparscpic vertical banded gastrplasty Intestinal bypass surgery (Jejunileal bypass) Gastric balln fr treatment f besity (e.g. Obaln Balln, swallwable intragastric balln system) Gastric bypass using a Billrth II type f anastmsis (Mini-gastric bypass, laparscpic) Exercise prgrams ther than thse included in a cmprehensive multi-disciplinary bariatric prgram Restrative besity surgery endscpy (ROSE) prcedure Gastric electrical stimulatin Silastic ring vertical gastric banding (e.g. Fbi Puch) Multiple bariatric surgical prcedures Cding: Cdes are listed belw fr infrmatinal purpses. The list may nt be all-inclusive, and des nt imply r guarantee cverage r prvider reimbursement. Eligibility, benefits, limitatins, exclusins, precertificatin/referral requirements, prvider cntracts, and Harvard Pilgrim plicies apply. Bariatric Surgeries Page 5 f 9 HPHC plicies are based n medical science, and written fr the majrity f peple with a given cnditin. Cverage described in this plicy is standard under mst HPHC plans. Specific benefits may vary by prduct and/r emplyer grup. Please reference apprpriate member materials (e.g., Benefit Handbk, Certificate f Cverage) fr member-specific benefit infrmatin.

6 CPT Cde Descriptin Laparscpy, surgical, gastric restrictive prcedure; with gastric bypass and Rux-en-Y gastrenterstmy (rux limb 150 cm r less) Laparscpy, surgical, gastric restrictive prcedure; with gastric bypass and small intestine recnstructin t limit absrptin Unlisted laparscpy prcedure, stmach Laparscpy, surgical, gastric restrictive prcedure; placement f adjustable gastric restrictive device (e.g., gastric band and subcutaneus prt cmpnents) Laparscpy, surgical, gastric restrictive prcedure; revisin f adjustable gastric restrictive device cmpnent nly Laparscpy, surgical, gastric restrictive prcedure; remval f adjustable gastric restrictive device cmpnent nly Laparscpy, surgical, gastric restrictive prcedure; remval and replacement f adjustable gastric restrictive device cmpnent nly Laparscpy, surgical, gastric restrictive prcedure; remval f adjustable gastric restrictive device and subcutaneus prt cmpnents Laparscpy, surgical, gastric restrictive prcedure; lngitudinal gastrectmy (i.e., sleeve gastrectmy) Gastric restrictive prcedure with partial gastrectmy, pylrus-preserving dudenilestmy and ileilestmy (50 t 100 cm cmmn channel) t limit absrptin (bilipancreatic diversin with dudenal switch) Gastric restrictive prcedure, with gastric bypass fr mrbid besity; with shrt limb (150 cm r less) Rux-en-Y gastrenterstmy Gastric restrictive prcedure, with gastric bypass fr mrbid besity; with small intestine recnstructin t limit absrptin Revisin, pen, f gastric restrictive prcedure fr mrbid besity, ther than adjustable gastric restrictive device (separate prcedure) Gastric restrictive prcedure, pen; revisin f subcutaneus prt cmpnent nly Gastric restrictive prcedure, pen; remval f subcutaneus prt cmpnent nly Gastric restrictive prcedure, pen; remval and replacement f subcutaneus prt cmpnent nly ICD-10 Cdes Descriptin E11.9 Type 2 diabetes E Type 2 diabetes with arthrpathy E11.8 Type 2 diabetes with cmplicatin E11.69 Type 2 diabetes with cmplicatin, specified NEC E13.10 Cardirenal hypertensin E66.01 Mrbid besity E66.2 Mrbid besity with alvelar hypventilatin E66.8 Obesity, specified type NEC G47.33 Obstructive sleep apnea G93.2 Pseudtumr cerebri I10 Hypertensin I11.9 Hypertensive heart disease withut heart failure I13.0 Cardirenal hypertensin with heart failure I77.9 Crnary artery disease Bariatric Surgeries Page 6 f 9 HPHC plicies are based n medical science, and written fr the majrity f peple with a given cnditin. Cverage described in this plicy is standard under mst HPHC plans. Specific benefits may vary by prduct and/r emplyer grup. Please reference apprpriate member materials (e.g., Benefit Handbk, Certificate f Cverage) fr member-specific benefit infrmatin.

7 ICD-10 Cdes Descriptin I51.4-I51.9 Hypertensin, heart cnditins due t hypertensin K76.0 Steatsis liver NEC I25.5 Ischemic Cardimypathy I27.0 Primary Pulmnary Hypertensin E78.1 Pure Hyperglyceridemia K21.0 Gastr-Esphageal Reflux Disease with Esphagitis K21.9 Gastr-Esphageal Reflux Disease Withut Esphagitis E88.81 Metablic Syndrme N39.3 Stress Incntinence (Female) (Male) K75.81 Nnalchlic Steathepatitis (Nash) I87.2 Venus Insufficiency (Chrnic) (Peripheral) References: 1. Standards f Medical Care in Diabetics Available at: bined_final.6-99.pdf 2. Abramf R. Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes. Yearbk f Medicine. 2012;2012: di: /s (12) Ness-Abramf R. Bariatric Surgery versus Cnventinal Medical Therapy fr Type 2 Diabetes. Yearbk f Endcrinlgy. 2012;2012: di: /j.yend Behrns K. Bariatric Surgery and Lng-term Cardivascular Events. Yearbk f Surgery. 2012;2012: di: /j.ysur Heneghan H, Mern-Eldar S, Brethauer S, Schauer P, Yung J. Effect f Bariatric Surgery n Cardivascular Risk Prfile Drs. Heneghan and Mern-Eldar cntributed equally t this article. The American Jurnal f Cardilgy. 2011;108(10): di: /j.amjcard Lng-Term Mrtality After Gastric Bypass Surgery. Survey f Anesthesilgy. 2008;52(2):94. di: /01.sa Bariatric surgery: a systematic review and meta-analysis. Obstetrics & Gyneclgy. 2005;105(1): di: /01.ag Gastrintestinal Surgery fr Severe Obesity March Obesity Surgery. 1991;1(3): di: / ASMBS pediatric cmmittee best practice guidelines. Surgery fr Obesity and Related Diseases. ASMBS Pediatric Cmmittee Best Practice Guidelines. 2012;8: Best Practice Updates fr Pediatric/Adlescent Weight Lss Surgery. Obesity. 2009; 17(5): Metablic and Bariatric Surgery Available at: Accessed February 27, Mechanick JI, Kushner RF, Sugerman HJ, Gnzalez-Campy JM, Cllaz-Clavell ML, Guven S, et al. American Assciatin f Clinical Endcrinlgists, The Obesity Sciety, and American Sciety fr Metablic & Bariatric Surgery Medical guidelines fr clinical practice fr the periperative nutritinal, metablic, and nnsurgical supprt f the bariatric surgery patient. Endcr Pract Jul-Aug;14 Suppl 1: Tevis S, Garren M, Guld J. Revisinal Surgery fr Failed Vertical-Banded Gastrplasty. Obesity Surgery. 2011;21(8): di: /s Bariatric Surgeries Page 7 f 9 HPHC plicies are based n medical science, and written fr the majrity f peple with a given cnditin. Cverage described in this plicy is standard under mst HPHC plans. Specific benefits may vary by prduct and/r emplyer grup. Please reference apprpriate member materials (e.g., Benefit Handbk, Certificate f Cverage) fr member-specific benefit infrmatin.

8 14. Gluck B, Mvitz B, Jansma S, Gluck J, Laskwski K. Laparscpic Sleeve Gastrectmy is a Safe and Effective Bariatric Prcedure fr the Lwer BMI ( kg/m2) Ppulatin. Obesity Surgery. 2010;21(8): di: /s Pub Medicare Natinal Cverage Determinatins. 1st ed. Centers fr Medicare and Medicaid Services; Available at: Guidance/Guidance/Transmittals/dwnlads/R158NCD.pdf. Accessed February 28, Christu N, Lk D, MacLean L. Weight Gain After Shrt- and Lng-Limb Gastric Bypass in Patients Fllwed fr Lnger Than 10 Years. Annals f Surgery. 2006;244(5): di: /01.sla d Hayes, Inc. Laparscpic Bariatric Surgery: Ruxeny Gastric Bypass, Vertical Banded Gastrplasty And Adjustable Gastric Banding. 18. UpTDate. Medical Outcmes Fllwing Bariatric Surgery.; MassHealth. Guidelines Fr Medical Necessity Determinatin Fr Bariatric Surgery.; American Sciety fr Metablic and Bariatric Surgery. Medical And Gvernment Grups Supprt Bariatric Surgery.; Lcal Cverage Determinatin (LCD): Bariatric Surgical Management f Mrbid Obesity (L35022). Cmsgv Available at: Accessed March 10, Guidelines fr Clinical Applicatin f Laparscpic Bariatric Surgery - A SAGES Guideline. SAGES Available at: Accessed March 10, Buchwald H. Cnsensus Cnference Statement Bariatric Surgery Fr Mrbid Obesity: Health Implicatins Fr Patients, Health Prfessinals, And Third-Party Payers. 1st ed.; Available at: Accessed March 10, Pinheir J, Schiavn C, Pereira P, Crrea J, Nujaim P, Chen R. Lng-lng limb Rux-en-Y gastric bypass is mre efficacius in treatment f type 2 diabetes and lipid disrders in super-bese patients. Surgery fr Obesity and Related Diseases. 2008;4(4): di: /j.sard Gleysteen J. Five-year utcme with gastric bypass: Rux limb length makes a difference. Surgery fr Obesity and Related Diseases. 2009;5(2): di: /j.sard Obesity Management ICER. Icer-reviewrg Available at: Accessed March 10, ECRI Institute. Intragastric Ballns (Obaln, Orbera, And Reshape) Fr Treating Obesity.; Available at: Accessed March 10, SUMMARY OF SAFETY AND EFFECTIVENESS DATA (SSED): Obaln. 1st ed.; Available at: Accessed March 10, Summary f Changes: Date Changes 5/2/17 Backgrund and references updated and refrmatted. Cverage criteria and cding revised. 12/15 Cding added. Frmatting and references updated. Update frmat and references. Delete Vertical Banded Gastrplasty (VBG) frm list f cvered prcedures; add t list f exclusins. Add ftnte re: cverage fr bariatric surgery in patients with cmpensated cirrhsis and mild prtal hypertensin. Bariatric Surgeries Page 8 f 9 HPHC plicies are based n medical science, and written fr the majrity f peple with a given cnditin. Cverage described in this plicy is standard under mst HPHC plans. Specific benefits may vary by prduct and/r emplyer grup. Please reference apprpriate member materials (e.g., Benefit Handbk, Certificate f Cverage) fr member-specific benefit infrmatin.

9 Apprved by UMCPC: 5/2/17 Reviewed/Revised: 1/03, 12/03, 1/05, 1/06, 3/06, 5/07, 12/07, 2/08, 6/08, 5/09, 7/09, 5/10, 4/11, 5/12, 6/13, 7/14, 10/14, 12/15, 5/17 Initiated: 11/01 Bariatric Surgeries Page 9 f 9 HPHC plicies are based n medical science, and written fr the majrity f peple with a given cnditin. Cverage described in this plicy is standard under mst HPHC plans. Specific benefits may vary by prduct and/r emplyer grup. Please reference apprpriate member materials (e.g., Benefit Handbk, Certificate f Cverage) fr member-specific benefit infrmatin.