Medical Policy Original Effective Date: Revised Date: Page 1 of 23

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1 Page 1 of 23 Disclaimer Description Coverage Determination Refer to the member s specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefit on all plans or the plan may have broader or more limited benefits than those listed in this. The goal for surgical treatment of obesity is to reduce the impact of serious illness or comorbidities that are induced or aggravated by obesity. Weight-loss surgery should be used only for those members who have tried and failed other methods of treatment, including a medically supervised weight loss program. Weight loss surgery is an option for carefully selected patients with a BMI of 35 to 39.9 kg/m 2 who are at a high risk for increased morbidity. A successful surgical outcome depends upon the member s motivation, education and psychological state. Bariatric surgery requires Prior Authorization. Logon to Pres Online to submit a request: Bariatric surgery procedures performed to treat comorbid conditions associated with morbid obesity are a covered benefit. I. Bariatric surgery is covered when ALL of the following criteria are met: A. The patient must be 18 years of age or older. AND B. Appropriate non-surgical treatment should have been attempted prior to surgical treatment for obesity, as evidenced by documented oversight of a structured diet program within the past year supervised by a physician and/or appropriately licensed nutrition specialist, such as a registered dietician or a licensed nutritionist. Physician programs which only provide pharmacological management are not sufficient. Documented oversight includes records of weight/bmi, dietary program, exercise regimen, behavioral health interventions and pharmacotherapies, if any. The documented BMI at the starting date of the diet program is the BMI used for bariatric surgery. AND C. The member will attend a weight loss seminar presented by the bariatric center where the surgery will be performed; the weight loss seminar explains the various aspects of weight loss surgery, including available surgical options, potential complications and supportive resources.

2 Page 2 of 23 AND D. Behavioral health assessment and clearance by a licensed psychologist or psychiatrist associated with or recommended by the specific surgical program to which the patient has been referred. Evaluation should address potential difficulties the patient may have in adapting to the physical/psychological and other lifestyle/eating changes that will result from the surgery. Specifically, assessment should address: a) The presence of psychiatric risks or active substance abuse that would affect the ability to follow healthcare instruction, b) eating patterns and eating disorders that may require psychotherapeutic intervention either pre- or post-operatively, and c) the patient s expectations with respect to outcome and whether those expectations are likely to facilitate or hinder adjustment to the necessary behavioral changes. Psychological testing should include objective/normed instruments for depression, anxiety, or other psychiatric risks. AND E. Must meet one of the following physiologic parameter: 1. A BMI of 40 kg/m or greater; OR 2. A BMI 35 kg/m², and one or more serious obesity-related comorbidities that put the member clearly at risk for decreased life expectancy if weight is not lost. Member must have demonstrated adherence with all prescribed medications and treatment instructions. Appropriate documentation is required. Specific obesity-related comorbidities include, but are not limited to: Cardiomyopathy. Congestive heart failure with an ejection fraction of 50% or less than predicted. Documentation of previous myocardial infarction requiring hospitalization. Documented Type 2 diabetes mellitus Uncontrolled /massive leg lymphedema. Obstructive sleep apnea with a baseline AHI or RDI of 15 or greater, or currently under treatment with a positive pressure device (CPAP, BiPAP, C-Flex, etc.) Obesity related osteoarthritis of the lower extremities for which joint replacement surgery of the knee or ankle has been recommended but deferred due to obesity. Pickwickian syndrome or cor pulmonale.

3 Page 3 of 23 Obesity related hypertension that is clinically significant and unresponsive to medical therapy Systolic BP 140 or greater and/or diastolic BP 90. Documentation must be provided proving that these conditions persist despite optimal medical treatment as prescribed by the practitioner and member adherence to treatment. LDL cholesterol that is clinically significant and unresponsive to medical therapy greater than 150. Documentation must be provided proving that these conditions persist despite optimal medical treatment as prescribed by the practitioner and member adherence to treatment. II. Bariatric surgery for all covered members must be performed by an accredited facility by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program as a Comprehensive Center. III. The following bariatric surgery procedures are covered: Open and laparoscopic Roux-n-Y gastric bypass(rygbp) Laparoscopic adjustable gastric banding (LAGB) Open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) Laparoscopic Sleeve Gastrectomy(Laparoscopic Sleeve Gastrectomy for a 'stand-alone' procedure (i.e., not as part of staged procedure or part of failed attempt that moves to an open procedure) Single Anastomosis Duodenal Switch (under IRB review) Exclusions The following bariatric surgery procedures are NOT covered: Intestinal bypass surgery Gastric balloon for treatment of obesity Open or laparoscopic vertical banded gastroplasty Open adjustable gastric banding Open sleeve gastrectomy Intestinal by pass Mini-gastric bypass Silastic ring vertical gastric bypass (Fobi pouch) Additional exclusions: Life-threatening multisystemic organ failure Uncontrolled or metastatic malignancy or other serious medical condition where caloric restriction may compromise the member

4 Page 4 of 23 Severe or unstable psychiatric illness that would prevent adjustment post-surgery Untreated endocrine dysfunction Pregnancy or lactation Active systemic infection Uncontrolled HIV infection History of unresolved noncompliance, either medical or psychosocial History of alcohol or substance abuse within the last six months History of smoking within the last three months Coverage plans that exclude bariatric surgery as a benefit Background There are two major types of weight loss surgery. One type diverts food from the stomach to a lower portion of the digestive tract, creating malabsorption (Malabsorption Procedure). The other type restricts the size of the stomach and decreases intake (Restrictive Procedure). Some weight loss surgeries combine both types of procedures (Combined Malabsorption and Restrictive Procedure). Reduction in the size of the stomach or malabsorption leads to decreased caloric intake, and results in significant weight loss. The surgeon performing the bariatric surgery should be substantially experienced and be working within an integrated program that provides for adequate and appropriate oversight, assessment, and management of these procedures. This multidisciplinary program should include guidance on diet, exercise and psychosocial concerns before and after surgery. Presbyterian Health Plan s Clinical Guidelines for the treatment of obesity follow the Practical Guide to the Identification, Evaluation and Treatment of Overweight and Obesity in Adults, developed cooperatively by the North American Association for the Study of Obesity and the National Heart, Lung and Blood Institute. These guidelines describe how healthcare professionals can provide their patients with the direction and support needed to effectively lose weight. The guidelines provide information on lifestyle changes, and the appropriate use of pharmacotherapy and surgery as treatment options.

5 Page 5 of 23 Coding Reporting of ICD-10 for the following CPT The coding listed in this is for reference only. Covered and non-covered codes are included in this list. For the following CPT/HCPCS codes 43644, 43645, 43770, 43775, 43845, 43846, and Note: Assign ICD-10 E66.01 (morbid obesity) as primary. Report a secondary diagnosis from Table 1 and a tertiary diagnosis from Table 2. For the following CPT/HCPCS codes 43659, 43771, 43772, 43773, 43774, 43886, and Coverage for replacing a defective device or correcting a complication in a patient who had met medical necessity for the original procedure and has achieved acceptable weight loss requires reporting of one diagnosis. The following list includes only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary. See ICD-10 codes in Table 3 for covered diagnosis Current Procedural Terminology (CPT) Codes CPT Codes Description Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less). Laparoscopy with gastric bypass and small intestine reconstruction to limit absorption. (Do not report in conjunction with 49320, 43847) Unlisted laparoscopy procedure, stomach. (use CPT code when BOTH the gastric band and subcutaneous port components were removed AND replaced. Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components). *Note: The diagnosis of K21.0 is not covered for CPT code Revision of adjustable gastric band component only Removal of adjustable gastric band component only Removal and replacement of adjustable gastric band component only Removal of adjustable gastric band and subcutaneous port components

6 Page 6 of 23 CPT Codes Description Laparoscopy, surgical, gastric restrictive procedure; Longitudinal Gastrectomy (ie sleeve gastrectomy). Laparoscopic Sleeve Gastrectomy for a 'stand-alone' procedure (i.e., not as part of staged procedure or part of failed attempt that moves to an open procedure) V-Band and gastroplasty Gastroplasty w/out V-band Gastric restrictive procedure with partial gastrectomy, pyloruspreserving 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. (For greater than 150 cm, use ) (For laparoscopic procedure, use ) With small intestine to limit absorption Revision, open of gastric restrictive procedure for morbid obesity, other than adjustable gastric band (separate procedure) 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 Stomach surgery procedure 2018 HCPCS Code HCPCS Codes S2083 Description Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline Diagnosis Coverage for selected bariatric surgery procedures (CPT codes: 43644, 43645, 43770, 43775,

7 Page 7 of , 43846, and 43848), requires reporting three appropriate diagnoses. Report the primary diagnosis as E66.01 (morbid obesity). Report a secondary diagnosis from Table 1 and a tertiary diagnosis from Table 2 below. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary. A18.84 Tuberculosis of heart E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma E11.21 Type 2 diabetes mellitus with diabetic nephropathy E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E E E E E E E E E E Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye

8 Page 8 of 23 E E E E E E E E E E E E E E E E E E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye with macular edema, right eye with macular edema, left eye

9 Page 9 of 23 E E E E E E E E E E E E E E E with macular edema, bilateral with macular edema, unspecified eye with traction retinal detachment involving the macula, right eye with traction retinal detachment involving the macula, left eye with traction retinal detachment involving the macula, bilateral with traction retinal detachment involving the macula, unspecified eye with traction retinal detachment not involving the macula, right eye with traction retinal detachment not involving the macula, left eye with traction retinal detachment not involving the macula, bilateral with traction retinal detachment not involving the macula, unspecified eye with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye

10 Page 10 of 23 E E E E E E E Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye without macular edema, right eye without macular edema, left eye without macular edema, bilateral without macular edema, unspecified eye E11.36 Type 2 diabetes mellitus with diabetic cataract E11.37X1 E11.37X2 E11.37X3 E11.39 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral Type 2 diabetes mellitus with other diabetic ophthalmic complication E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy E11.44 Type 2 diabetes mellitus with diabetic amyotrophy E11.49 Type 2 diabetes mellitus with other diabetic neurological complication

11 Page 11 of 23 E11.51 E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications E Type 2 diabetes mellitus with diabetic neuropathic arthropathy E Type 2 diabetes mellitus with other diabetic arthropathy E Type 2 diabetes mellitus with diabetic dermatitis E Type 2 diabetes mellitus with foot ulcer E Type 2 diabetes mellitus with other skin ulcer E Type 2 diabetes mellitus with other skin complications E Type 2 diabetes mellitus with periodontal disease E Type 2 diabetes mellitus with other oral complications E Type 2 diabetes mellitus with hypoglycemia with coma E Type 2 diabetes mellitus with hypoglycemia without coma E11.65 Type 2 diabetes mellitus with hyperglycemia E11.69 Type 2 diabetes mellitus with other specified complication E11.8 Type 2 diabetes mellitus with unspecified complications E11.9 Type 2 diabetes mellitus without complications E13.00 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)

12 Page 12 of 23 E13.01 Other specified diabetes mellitus with hyperosmolarity with coma E13.10 Other specified diabetes mellitus with ketoacidosis without coma E13.11 Other specified diabetes mellitus with ketoacidosis with coma E13.21 Other specified diabetes mellitus with diabetic nephropathy E13.22 E13.29 E E E E E E E E E E E E Other specified diabetes mellitus with diabetic chronic kidney disease Other specified diabetes mellitus with other diabetic kidney complication Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye

13 Page 13 of 23 E E E E E E E E E E E E E E E E E E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye retinopathy with macular edema, right eye retinopathy with macular edema, left eye retinopathy with macular edema, bilateral retinopathy with macular edema, unspecified eye

14 Page 14 of 23 E E E E E E E E E E E E E E E retinopathy with traction retinal detachment involving the macula, right eye retinopathy with traction retinal detachment involving the macula, left eye retinopathy with traction retinal detachment involving the macula, bilateral retinopathy with traction retinal detachment involving the macula, unspecified eye retinopathy with traction retinal detachment not involving the macula, right eye retinopathy with traction retinal detachment not involving the macula, left eye retinopathy with traction retinal detachment not involving the macula, bilateral retinopathy with traction retinal detachment not involving the macula, unspecified eye retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral

15 Page 15 of 23 E E E E E Other specified diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye retinopathy without macular edema, right eye retinopathy without macular edema, left eye retinopathy without macular edema, bilateral retinopathy without macular edema, unspecified eye E13.36 Other specified diabetes mellitus with diabetic cataract E13.37X1 E13.37X2 E13.37X3 E13.37X9 E13.39 E13.40 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, right eye Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, left eye Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye Other specified diabetes mellitus with other diabetic ophthalmic complication Other specified diabetes mellitus with diabetic neuropathy, unspecified E13.41 Other specified diabetes mellitus with diabetic mononeuropathy E13.42 Other specified diabetes mellitus with diabetic polyneuropathy E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy E13.44 Other specified diabetes mellitus with diabetic amyotrophy E13.49 E13.51 Other specified diabetes mellitus with other diabetic neurological complication Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene

16 Page 16 of 23 E13.52 E13.59 E Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene Other specified diabetes mellitus with other circulatory complications Other specified diabetes mellitus with diabetic neuropathic arthropathy E Other specified diabetes mellitus with other diabetic arthropathy E Other specified diabetes mellitus with diabetic dermatitis E Other specified diabetes mellitus with foot ulcer E Other specified diabetes mellitus with other skin ulcer E Other specified diabetes mellitus with other skin complications E Other specified diabetes mellitus with periodontal disease E Other specified diabetes mellitus with other oral complications E Other specified diabetes mellitus with hypoglycemia with coma E Other specified diabetes mellitus with hypoglycemia without coma E13.65 Other specified diabetes mellitus with hyperglycemia E13.69 Other specified diabetes mellitus with other specified complication E13.8 Other specified diabetes mellitus with unspecified complications E13.9 Other specified diabetes mellitus without complications E66.2 Morbid (severe) obesity with alveolar hypoventilation E78.00 Pure hypercholesterolemia, unspecified

17 Page 17 of 23 E78.1 Pure hyperglyceridemia E78.2 Mixed hyperlipidemia E78.3 Hyperchylomicronemia E78.4 Other hyperlipidemia E78.5 Hyperlipidemia, unspecified G47.33 Obstructive sleep apnea (adult) (pediatric) G47.36 Sleep related hypoventilation in conditions classified elsewhere G93.2 Benign intracranial hypertension I10 Essential (primary) hypertension I27.29 Other secondary pulmonary hypertension I27.89 Other specified pulmonary heart diseases I43 K21.0* Cardiomyopathy in diseases classified elsewhere Gastro-esophageal reflux disease with esophagitis. *Note: The diagnosis of K21.0 is not covered for CPT code K75.81 Nonalcoholic steatohepatitis (NASH) K76.0 Fatty (change of) liver, not elsewhere classified K76.89 Other specified diseases of liver M15.3 Secondary multiple arthritis M15.8 Other polyosteoarthritis

18 Page 18 of 23 M16.0 Bilateral primary osteoarthritis of hip M16.10 Unilateral primary osteoarthritis, unspecified hip M16.11 Unilateral primary osteoarthritis, right hip M16.12 Unilateral primary osteoarthritis, left hip M16.2 Bilateral osteoarthritis resulting from hip dysplasia M16.30 Unilateral osteoarthritis resulting from hip dysplasia, unspecified hip M16.31 Unilateral osteoarthritis resulting from hip dysplasia, right hip M16.32 Unilateral osteoarthritis resulting from hip dysplasia, left hip M16.4 Bilateral post-traumatic osteoarthritis of hip M16.50 Unilateral post-traumatic osteoarthritis, unspecified hip M16.51 Unilateral post-traumatic osteoarthritis, right hip M16.52 Unilateral post-traumatic osteoarthritis, left hip M16.6 Other bilateral secondary osteoarthritis of hip M16.7 Other unilateral secondary osteoarthritis of hip M16.9 Osteoarthritis of hip, unspecified M17.0 Bilateral primary osteoarthritis of knee M17.10 Unilateral primary osteoarthritis, unspecified knee M17.11 Unilateral primary osteoarthritis, right knee

19 Page 19 of 23 M17.12 Unilateral primary osteoarthritis, left knee M17.2 Bilateral post-traumatic osteoarthritis of knee M17.30 Unilateral post-traumatic osteoarthritis, unspecified knee M17.31 Unilateral post-traumatic osteoarthritis, right knee M17.32 Unilateral post-traumatic osteoarthritis, left knee M17.4 Other bilateral secondary osteoarthritis of knee M17.5 Other unilateral secondary osteoarthritis of knee M17.9 Osteoarthritis of knee, unspecified M Primary osteoarthritis, right ankle and foot M Primary osteoarthritis, left ankle and foot M Primary osteoarthritis, unspecified ankle and foot M Post-traumatic osteoarthritis, right ankle and foot M Post-traumatic osteoarthritis, left ankle and foot M Post-traumatic osteoarthritis, unspecified ankle and foot M Secondary osteoarthritis, right ankle and foot M Secondary osteoarthritis, left ankle and foot M Secondary osteoarthritis, unspecified ankle and foot M19.90 Unspecified osteoarthritis, unspecified site

20 Page 20 of 23 M Spinal stenosis, lumbar region with neurogenic claudication M48.07 Spinal stenosis, lumbosacral region M51.06 Intervertebral disc disorders with myelopathy, lumbar region M51.36 Other intervertebral disc degeneration, lumbar region M51.37 Other intervertebral disc degeneration, lumbosacral region M99.23 Subluxation stenosis of neural canal of lumbar region M99.33 Osseous stenosis of neural canal of lumbar region M99.43 Connective tissue stenosis of neural canal of lumbar region M99.53 Intervertebral disc stenosis of neural canal of lumbar region M99.63 M99.73 Osseous and subluxation stenosis of intervertebral foramina of lumbar region Connective tissue and disc stenosis of intervertebral foramina of lumbar region Tertiary Diagnoses ICD-10 Tertiary Diagnoses (Table 2) Z68.35 Body mass index (BMI) , adult Z68.36 Body mass index (BMI) , adult Z68.37 Body mass index (BMI) , adult Z68.38 Body mass index (BMI) , adult Z68.39 Body mass index (BMI) , adult Z68.41 Body mass index (BMI) , adult Z68.42 Body mass index (BMI) , adult

21 Page 21 of 23 ICD-10 Tertiary Diagnoses (Table 2) Z68.43 Body mass index (BMI) , adult Z68.44 Body mass index (BMI) , adult Z68.45 Body mass index (BMI) 70 or greater, adult Coverage for replacing a defective device or correcting a complication in a patient who had met medical necessity for the original procedure and has achieved acceptable weight loss requires reporting of one diagnosis. The following list includes only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary. The following are limited coverage for CPT/HCPCS codes 43659, 43771, 43772, 43773, 43774, 43886, and Diagnoses coverage for replacing a defective device or correcting complication ICD-10 Code Description (Table 3) T85.518A Breakdown (mechanical) of other gastrointestinal prosthetic devices, implants and grafts, initial encounter T85.528A Displacement of other gastrointestinal prosthetic devices, implants and grafts, initial encounter T85.598A Other mechanical complication of other gastrointestinal prosthetic devices, implants and grafts, initial encounter T85.612A Breakdown (mechanical) of permanent sutures, initial encounter T85.622A Displacement of permanent sutures, initial encounter T85.638A Leakage of other specified internal prosthetic devices, implants and grafts, initial encounter T85.692A Other mechanical complication of permanent sutures, initial encounter T85.79XA Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter T85.9XXA Unspecified complication of internal prosthetic device, implant and graft, initial encounter Reviewed References 1. Brenda L. Wolfe, Ph.D., Clinical Psychologist, Albuquerque, NM, January Michael D. Lara, MD, Rio Grande Surgeons, PA, El Paso, TX. August 2007, August Centers for Medicare and Medicaid Services. Bariatric Surgery for

22 Page 22 of 23 Treatment of Co-Morbid Conditions Related to Morbid Obesity (100.1), Version Number 5. Effective Date: May Accessed 07/24/ Centers for Medicare and Medicaid Servicers. Bariatric Surgical Management of Morbid Obesity (L35022), Revision R6. Effective Date: October 2017, updated 05/14/2018. Accessed 07/24/ Hayes Directory. Winifred S. Hayes, Inc. 4. Comparative Effectiveness Review of Bariatric Surgeries for Treatment of Obesity in Adolescents, May 17, Comparative Effectiveness of Roux-en-Y Gastric Bypass and Slee Gastrectomy for Treatment of Type II Diabetics. Publication date J 27, 2017 with annual review 07/10/2018. Accessed 07/ CMS, National Coverage Determination (NCD) for Intensive Behavioral Therapy for Obesity (210.12), effective date 11/29/ MCG Guidelines. Inpatient and Surgical Care, 21st Edition. Last Update Accessed 07/24/2018. Gastric Restrictive Procedure with Gastric Bypass, ORG: S- 512 (ISC) Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy, ORG: S-513 (ISC) Gastric Restrictive Procedure, Sleeve Gastrectomy, by Laparoscopy, ORG: S-516 (ISC) Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy, ORG: S-515 (ISC) Approval Signatures: Clinical Quality Committee: Tom Rothfeld MD Medical Director: Norman White MD Approval Date: Publishing History: May 23, 2018 Original Effective Date: June 23, 2004 Review Date: Aug 2005, May 2006, July 2007, July/Aug 2007, Aug/Sept 2008 Revision Date: Oct 2005, May 2006, Jan 2007, Sept 2007, Sept 2008 Renumbered to ICR 2.8 (previously 8.5): Jan : Transitioned to, Annual Review and Revision

23 Page 23 of : Revision : Annual Review and Revision : Annual Review and Revision : Update of language re All PHP members must utilize a facility approved by CMS : Annual Review and Update : Annual Review : Annual Review This is intended to represent clinical guidelines describing medical appropriateness and is developed to assist Presbyterian Health Plan and Presbyterian Insurance Company, Inc. (Presbyterian) Health Services staff and Presbyterian medical directors in determination of coverage. This is not a treatment guide and should not be used as such. For those instances where a member does not meet criteria described in these guidelines, additional information supporting medical necessity is welcome and may be used by the medical director in reviewing the case. Please note that all Presbyterian Medical Policies are available on the Internet at: