Medical Policy Bariatric Surgery. Document Number: 042 Commercial and Qualified Health Plans MassHealth Authorization required X X
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1 Medical Policy Bariatric Surgery Document Number: 042 Commercial and Qualified Health Plans MassHealth Authorization required X X No Prior Authorization Overview The purpose of this document is to describe the guidelines AllWays Health Partners utilizes to determine medical appropriateness for bariatric surgeries for AllWays Health Partners members. The treating specialist must request prior authorization for bariatric surgery. Coverage Guidelines AllWays Health Partners covers bariatric surgery for the treatment of severe obesity when such surgery is authorized prior to the procedure and meets medical necessity criteria. As of February 20, 2017, medical necessity for bariatric surgery is determined through McKesson s InterQual criteria. To access the criteria, log in to AllWays Health Partners provider website at allwaysprovider.org and click the InterQual Criteria Lookup link under the Resources Menu. Based upon McKesson s InterQual criteria, authorization of bariatric surgical procedures is limited to: 1. Roux-en-Y Gastric Bypass (RYGB) 2. Gastric Bypass using Biliopancreatic diversion (BPD) with duodenal switch (DS) 3. Sleeve gastrectomy; 4. Laparoscopic adjustable gastric banding (LAGB); 5. Adjustable Gastric Banding (AGB) (Repair, removal, and revision); 6. Revisional procedures including: a. Revision of gastroduodenal anastomosis with reconstruction b. Revision of gastrojejunal anastomosis with reconstruction Bariatric Surgery Vertical-banded Gastroplasty AllWays Health Partners covers revisional procedures for vertical-banded gastroplasty in the following situations: 1. If vertical-banded gastroplasty resulted in significant complications, and bariatric correction surgery needed to be performed through the RYGB procedure. 2. If vertical-banded gastroplasty resulted in a lack of weight loss/fat inconsistent weight loss, and bariatric correction surgery needed to be performed through the RYGB procedure. Bariatric Surgery Revisional Procedures As of February 20, 2017, medical necessity for revisional procedures is determined through McKesson s InterQual criteria. To access the criteria, log in to AllWays Health Partners; provider website at allwaysprovider.org and click the InterQual Criteria Lookup link under the Resources Menu. AllWays Health Partners includes AllWays Health Partners, Inc. and AllWays Health Partners Insurance Company 1
2 Definitions Bariatric surgery: Non-cosmetic, surgical procedures used in the treatment of morbid obesity. Body Mass Index (BMI): is calculated by dividing the patient s weight, in kilograms, by height, in meters, squared. Conversion Surgery: A surgery that changes one type of procedure to a different type of procedure. Corrective Surgery: Surgical procedures addressing complications or an incomplete treatment effect of a prior surgery, without changing the type of procedure. May include reversal procedures that restore the original anatomy. CPT/HCPC Codes Authorized CPT/HCPCS Codes Code Description Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components) Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty Gastric restrictive procedure with partial gastrectomy, pyloruspreserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) AllWays Health Partners includes AllWays Health Partners, Inc. and AllWays Health Partners Insurance Company 2
3 S2083 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; without vagotomy Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; with vagotomy Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy Gastric restrictive procedure, open; revision of subcutaneous port component only Gastric restrictive procedure, open; removal of subcutaneous port component only Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline* *S2083 does not require Prior Authorization Effective January 2019: Annual review. References updated. March 2018: Added CPT, HCPC codes. September 2017: Annual review. Clarified coverage criteria for Vertical-banded Gastroplasty by adding revisional procedures. February 2017: Changes reflect the addition of InterQual criteria for Gastric Bypass using Roux-en-Y, Gastric Bypass using biliopancreatic diversion with duodenal switch, Sleeve gastrectomy, Laparoscopic adjustable gastric banding, Adjustable Gastric Banding and Revision procedures. September 2016: Annual review. September 2015: Smoking cessation counselling added, and references updated. September 2014: Reoperation, revision, and surgery to criteria Added. February 2014: Annual review. AllWays Health Partners includes AllWays Health Partners, Inc. and AllWays Health Partners Insurance Company 3
4 February 2013: gastric placation added to excluded procedures, specified adolescent criteria added. January 2012: Modified age requirement for bariatric surgeries, Removed specific requirements for laparoscopic Sleeve surgery. January 2011: Annual review. March 2010: Annual review. January 2009: Annual review. January 2008: Annual review. January 2007: Annual review. January 2006: Annual review. January 2005: Annual review. September 2002: Policy Effective. References 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. JACC, 2014; 63: American Association of Clinical Endocrinologists/ The Obesity Society/American Society for Bariatric Surgery, Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient 2013 Update: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surgery for Obesity and Related Diseases, 2013, 9: American Society for Metabolic & Bariatric Surgery (2011) ASMBS policy statement on gastric plication. Surgery for Obesity and Related Diseases, 2011, 7: 262. Society Review October American Society for Metabolic & Bariatric Surgery (2012) ASMBS position statement: bariatric surgery in class 1 obesity (BMI kg/m 2 ). Surgery for Obesity and Related Diseases, 2013, 9: e1 e10 American Society for Metabolic & Bariatric Surgery (2011) Updated position statement on sleeve gastrectomy as a bariatric procedure. Surgery for Obesity and Related Diseases, 2012, 8: e21-e26 American Society for Metabolic & Bariatric Surgery (2012) Pediatric committee best practice guidelines. Surgery for Obesity and Related Diseases, 2012, 8: 1-7. Birkmeyer, John D., et al. Surgical skill and complication rates after bariatric surgery. New England Journal of Medicine. 2013; 369: Brethhauer, SA et al. Systemic Review of sleeve gastrectomy as staging and primary bariatric procedure. Surgery for Obesity and Related Diseases, 2009: 5; Buchwald H. Ikramuddin S. Laparoscopic adjustable gastric banding in bariatric surgery: an overview of the LAP-BAND. Introduction. American Journal of Surgery. 2002; 184(6B):1S-3S AllWays Health Partners includes AllWays Health Partners, Inc. and AllWays Health Partners Insurance Company 4
5 Centers for Medicare and Medicaid Services. National coverage determination (NCD) for Bariatric Surgery for Treatment of Morbid Obesity (100.1). at: Accessed 6/2015 Chang, SH, et al. The Effectiveness and Risks of Bariatric Surgery: An Updated Systematic Review and Meta-analysis, JAMA Surgery 2014; 149: Colquitt, JL., Picot, J., et al. Surgery for obesity (review). Cochrane Database of Systematic Reviews; 2014, August 8. Dimick, JB., et al. Bariatric Surgery Complications Before vs After Implementation of a National Policy Restricting Coverage to Centers of Excellence: Complications Following Bariatric Procedures. JAMA, 2013; 309: Dixon JB. O'Brien PE. Changes in comorbidities and improvements in quality of life after Lap-Band placement. American Journal of Surgery, 2002; 184(6B):51S-54S Elbanna A, Eldin MT, Fathy M, et al. Bariatric Bypass Surgery to Resolve Complicated Childhood Morbid Obesity. Medicine. 2015;94(49). doi: /md Fulton, C, et al. A comparison of revisional and primary bariatric surgery. Can J Surg (3): Franco, J., Palermo, P., Gangner, M. A review of studies comparing three laparoscopic procedures in bariatric surgery: sleeve gastrectomy, roux-en-y gastric bypass and adjustable gastric banding. Obesity Surgery, 2011; 21: Hayes Medical Technology Directory, Laparoscopic Sleeve Gastrectomy for Super Obesity in Adults, January 22, Accessed 12/2018. Hayes Medical Technology Directory, Revisional surgery for treatment of complications after bariatric surgery. July 24, 2014, Accessed 12/2018. Hayes Medical Technology Directory Roux-en-Y Gastric Bypass for Diabetes in Obese or Severely Obese Patients, August 7, Accessed 12/2018. Hayes Medical Technology Search and Summary. Biliopancreatic Diversion with Duodenal Switch for Treatment of Obesity in Adults, July 17, Accessed 12/2018. Hayes Medical Technology Search and Summary. Preoperative Supervised Weight Loss Prior to Adult Bariatric Surgery, February 5, Accessed 12/2018. Hayes Medical Technology Search and Summary. Impact of Preoperative Supervised Weight Loss Programs on Bariatric Surgery Outcomes, August 10, Accessed 12/2018. Hayes Medical Technology Search and Summary. Roux-en-Y Gastric Bypass for Treatment of Obesity in Children, February 12,2015. Accessed 12/2018. AllWays Health Partners includes AllWays Health Partners, Inc. and AllWays Health Partners Insurance Company 5
6 Hayes Medical Technology Search and Summary. Sleeve Gastrectomy for Treatment of Obesity in Children, February 12,2015. Accessed 6/2015. Inge, Krebs, Garcia et. al., Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics. 2004; 114;217 Kehagias, I., Karamanakos, S., Argentou,M., Kalfarentzo F. Randomized clinical trial of laparoscopic roux-en-y-gastric bypass versus laparoscopic sleeve gastrectomy for the management of patients with BMI < 50 kg/m 2. Obese Surgery, 2011; 21: Lim CH., Abraham AA., et al. The future of the Roux-ex-Y gastric bypass. Expert review of gastroenterology & hepatology.2016; 10(7): MassHealth, Guidelines for Medical Necessity Determination for Bariatric Surgery, April 1, 2006, retrieved 2008, 2009, 2010, 2011, 2012, 2013, 2014, Tevis S, Garren MJ, Gould JC. Revisional surgery for failed vertical-banded gastroplasty. Obes Surg 2011 Aug;21(8): doi: /s AllWays Health Partners includes AllWays Health Partners, Inc. and AllWays Health Partners Insurance Company 6
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