LCD L Bariatric Surgical Management of Morbid Obesity

LCD L32619 - Bariatric Surgical Management of Morbid Obesity Contractor Information Contractor Name: Novitas Solutions, Inc. Contractor Number(s): 04911, 07101, 07102, 07201, 07202, 07301, 07302, 04111, 04112, 04211, 04212, 04311, 04312, 04411, 04412 Contractor Type: MAC Part A & B Go to Top LCD Information Document Information LCD ID Number L32619 LCD Title Bariatric Surgical Management of Morbid Obesity Contractor s Determination Number L32619 AMA CPT/ADA CDT Copyright Statement CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright Primary Geographic Jurisdiction Arkansas, Louisiana, Mississippi, Colorado, Texas, Oklahoma, New Mexico Oversight Region Central Office Original Determination Effective Date For services performed on or after 08/13/2012 Original Determination Ending Date N/A Revision Effective Date For services performed on or after 12/21/2012 Revision Ending Date N/A

American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. CMS National Coverage Policy This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for bariatric surgical services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for bariatric surgical services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies regarding bariatric surgical services are found in the following Internet-Only Manuals (IOMs) published on the CMS Web site: Medicare Benefit Policy Manual Pub. 100-02. Medicare National Coverage Determinations Manual Pub. 100-03, Chapter 1, Part 2, Sections 100.1, 100.8, 100.11 and 100.14. Correct Coding Initiative Medicare Contractor Beneficiary and Provider Communications Manual Pub. 100-09, Chapter 5. Social Security Act (Title XVIII) Standard References, Sections: 1862(a)(1)(A) Medically Reasonable & Necessary. 1862(a)(1)(D) Investigational or Experimental. 1862(a)(10) Cosmetic Surgery. 1833(e) Incomplete Claim. Jurisdiction H Notice: Jurisdiction H comprises the states of Arkansas, Louisiana, Mississippi, Colorado, New Mexico, Oklahoma, and Texas. Novitas is responsible for claims payment and Local Coverage Determination (LCD) development for this jurisdiction. This LCD was created as a part of the legacy transition (8/13/2012 11/19/2012); and, is a consolidation of the previous legacy contractors policies. Coverage of each LCD begins when the state/contract number combination officially is integrated into the Jurisdiction. On the CMS MCD, this date is known as either the Original Effective Date or the Revision Effective Date. The following table details the official effective dates for each state/contract number combination. ST Legacy A Contractor & Contract Number Legacy B Contractor & Contract Number J "H" MAC A Contractor & Contract Number J "H" MAC B Contractor & Contract Number J "H" Effective Date AR PBSI: 00520 (J7) 07102 08/13/12

LA PBSI: 00528 (J7) 07202 08/13/12 AR PBSI: 00020 (J7) 07101 08/20/12 LA PBSI: 00233 (J7) 07201 08/20/12 MS PBSI: 00233 (J7) 07301 08/20/12 MS Cahaba: 00512 (J7) 07302 10/22/12 J 4 States 04901 04911 10/29/12 CO 04101 04111 10/29/12 NM 04201 04211 10/29/12 OK 04301 04311 10/29/12 TX 04401 04411 10/29/12 CO 04102 04112 11/19/12 NM 04202 04212 11/19/12 OK 04302 04312 11/19/12 TX 04402 04412 11/19/12 Indications and Limitations of Coverage and/or Medical Necessity Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier. CMS National Coverage Policy Surgical treatment for primary obesity is not a covered Medicare service. CMS national policy dictates that surgery for morbid obesity is covered for Medicare

beneficiaries who have all of the following: A body mass index of 35 or higher. At least one comorbidity related to obesity. Have been previously unsuccessful with medical treatment for obesity. Bariatric surgical procedures are covered only when performed at facilities that are: (1) certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center (program standards and requirements in effect on February 15, 2006); or (2) certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (program standards and requirements in effect on February 15, 2006). Approved facilities and their approval dates are listed and maintained on the CMS coverage Web site: http://www.cms.gov/medicareapprovedfacilitie/bsf/list.asp Surgical procedures for morbid obesity that are covered under national policy for qualifying Medicare beneficiaries include: Open and laparoscopic Roux-en-Y Gastric Bypass (RYGBP). Open and laparoscopic Biliopancreatic Diversion With Duodenal Switch (BPD/DS). Laparoscopic Adjustable Gastric Banding (LAGB). Surgical procedures for morbid obesity that are not covered under national policy for all Medicare beneficiaries include: Open adjustable gastric banding. Open sleeve gastrectomy. Open and laparoscopic vertical-banded gastroplasty. Gastric balloon. Contractor Local Coverage Policy Bariatric surgery procedures must be performed by a surgeon trained and substantially experienced with surgery of the digestive tract, working in a clinical setting with adequate support for all aspects of management, assessment and follow-up. The American College of Surgeons (ACS) and American Society for Bariatric Surgery (ASBS) certification requirements for physician and institutional credentialing satisfy this requirement. Physicians and institutions who do not meet ACS or ASBS certification criteria for performing bariatric procedures do not qualify for Medicare payment for these procedures. Laparoscopic Sleeve Gastrectomy for morbid obesity is covered under Local Coverage Determination by this contractor to include patients with the three above criteria (BMI 35 or greater, at least one comorbidity related to obesity and previous unsuccessful medical treatment for obesity) as the following:

Laparoscopic Sleeve Gastrectomy only performed in a designated Medicare Center of Excellence for Bariatric Surgery 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) Under provisions of this LCD, the following procedures are also not covered: Intestinal bypass. Mini-gastric bypass. Silastic ring vertical gastric bypass (Fobi pouch). Comorbid Conditions Severe obesity is known to aggravate numerous medical conditions. Comorbid conditions for which bariatric surgery is covered include the following: Type II diabetes mellitus (by American Diabetes Association diagnostic criteria). Refractory hypertension (defined as blood pressure of 140 mmhg systolic and/or 90 mmhg diastolic despite medical treatment with maximal doses of three antihypertensive medications). Refractory hyperlipidemia (acceptable levels of lipids unachievable with diet and maximum doses of lipid lowering medications). Obesity-induced cardiomyopathy. Clinically significant obstructive sleep apnea. Obesity-related hypoventilation. Pseudotumor cerebri (documented idiopathic intracerebral hypertension). Severe arthropathy of spine and/or weight-bearing joints (when obesity prohibits appropriate surgical management of joint dysfunction treatable but for the obesity). Hepatic steatosis without prior evidence of active inflammation. Though the conditions listed above need not be immediately life-threatening for Medicare to cover bariatric surgery, the condition must not be trivial or easily controlled with noninvasive means (such as medication) and must be of sufficient severity as to pose considerable short- or long-term risk to function and/or survival. Consideration of the risk-benefit for each individual patient must be used to determine that surgery for obesity is the best option for treatment for that patient and no contraindications to bariatric surgery may exist. Previous Unsuccessful Medical Treatment for Obesity With or without bariatric surgery, successful obesity management requires adoption and lifelong practice of healthy eating and physical exercise (i.e. lifestyle modification) by the obese patient. Without adequate patient motivation and/or skills needed to make such lifestyle modifications, the benefit of bariatric surgical procedures is severely jeopardized and not medically reasonable or necessary. Patients considering bariatric surgical options must have been provided with knowledge and tools needed to achieve such lifelong

lifestyle changes and must be capable and willing to undergo the changes. For the purposes of this LCD, a patient will be deemed to have been unsuccessful with medical treatment of obesity if all of the following minimal requirements are met per documentation in the medical record: The patient meets BMI requirements stated in national policy (at the time of surgery). The patient has been provided with knowledge and tools needed to achieve such lifelong lifestyle changes, exhibits understanding of the needed changes and is demonstrated to clinicians involved in his or her care to be capable and willing to undergo the changes. The patient has made a diligent effort to achieve healthy body weight with such efforts described in the medical record and certified by the operating surgeon. The patient has failed to maintain a healthy weight despite adequate participation in a structured dietary program overseen by one of the following: Physician (MD or DO). Registered dietician (RD). Board certified specialist in pediatric nutrition (CSP). Board certified specialist in renal nutrition (CSR). Fellow of the American Dietetic Association (FADA). Preoperative Psychological/Psychiatric Evaluation An objective examination by a mental health professional (psychiatrist or psychologist) experienced in the evaluation and management of bariatric surgery candidates to exclude patients who are unable to personally provide informed consent, who are unable to comply with a reasonable pre- and postoperative regimen, or who have a significant risk of postoperative decompensation is recommended. Such evaluation is a Medicarecovered service. A diagnostic session is appropriate, and treatment sessions are appropriate if the patient has a diagnosable disorder that is likely to respond to psychotherapy. The mental health professional, the surgeon and the patient should be in agreement that the patient is an appropriate candidate for the surgery. Patients who have a history of psychiatric or psychological disorder or are currently under the care of a psychologist/psychiatrist, or are on psychotropic medications, must undergo preoperative psychological evaluation and clearance and the patient s record must include documentation of the evaluation and assessment. Other Preoperative Evaluation A patient undergoing bariatric surgical procedures should undergo preoperative evaluation that is medically reasonable and necessary based upon his comorbid medical conditions and medical/surgical history. All underlying medical conditions that will likely impact or complicate the patient s surgical and postoperative course must be adequately controlled before surgery. Routine preoperative testing (including upper gastrointestinal endoscopy) in the absence of signs/symptoms or personal history of a disease that could be negatively impacted by anesthesia or surgery is excluded from Medicare coverage by law. Postoperative Care Appropriate postoperative care for the bariatric surgery patient is required for Medicare

coverage of bariatric surgical procedures. Follow-up must include but not be limited to: Postoperative care by the operating surgeon immediately following surgery and throughout the global period for the surgery. At least three follow-up visits with the bariatric surgery team within the first year. Lifetime postoperative care for dietary issues (including vitamin, mineral and nutritional supplementation), exercise and lifestyle changes reinforced by counseling and/or support groups supervised by a physician knowledgeable in the long-term care of such patients. Contraindications to Bariatric Surgery Surgery for severe obesity is a major surgical intervention with a risk of significant early and late morbidity and perioperative mortality. Surgery for severe obesity is not covered in the presence of absolute contraindications, including the following: Prohibitive perioperative risk of cardiac complications due to cardiac ischemia or myocardial dysfunction. Severe chronic obstructive airway disease or respiratory dysfunction. Non-compliance with medical treatment of obesity or treatment of other chronic medical condition. Failure to cease tobacco use. Psychological/psychiatric conditions: Schizophrenia, borderline personality disorder, suicidal ideation, severe or recurrent depression, or bipolar affective disorders with difficult-to-control manifestations (e.g., history of recurrent lapses in control or recurrent failure to comply with management regimen). Mental retardation that prevents personally provided informed consent or the ability to understand and comply with a reasonable pre- and postoperative regimen. Any other psychological/psychiatric disorder that, in the opinion of a psychologist/psychiatrist, imparts a significant risk of psychological/psychiatric decompensation or interference with the longterm postoperative management. Note: A history of or presence of mild, uncomplicated and adequately treated depression due to obesity is not normally considered a contraindication to obesity surgery. History of significant eating disorders, including anorexia nervosa, bulimia and pica (sand, clay or other abnormal substance). Severe hiatal hernia/gastroesophageal reflux (for purely restrictive procedures such as LAGB). Autoimmune and rheumatological disorders (including inflammatory bowel diseases and vasculitides) that will be exacerbated by the presence of intra-abdominal foreign bodies (for LAGB procedure). Hepatic disease with prior documented inflammation, portal hypertension or ascites. Incidental Cholecystectomy Incidental cholecystectomy is covered in the presence of signs and/or symptoms of gallbladder disease, finding of a grossly diseased gallbladder at the time of operation or a history of metabolic derangements that will result in symptomatic gallbladder disease following bariatric procedures.

Repeat Bariatric Procedures Repeat bariatric surgery is generally not reasonable and necessary. Medicare does not provide prior authorization for these services. Claims for more than one bariatric surgical procedure most likely will create a denial. However, in the appeals process, medical documentation may be submitted for review and the service may potentially be covered when clinical circumstances demonstrate reasonability and necessity. Appropriate ABN and modifiers should be appended to any services potentially to be denied. Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. As published in CMS IOM 100-08, Section 13.5.1, in order to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is: Safe and effective. Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, that meet the requirements of the Clinical Trials NCD are considered reasonable and necessary). Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is: Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member. Furnished in a setting appropriate to the patient's medical needs and condition. Ordered and furnished by qualified personnel. One that meets, but does not exceed, the patient's medical needs. At least as beneficial as an existing and available medically appropriate alternative. Coding Information Bill Type Codes Go to Top Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

011x Hospital Inpatient (Including Medicare Part A) Revenue Codes Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes. Note: The Contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all the CPT/HCPCS codes listed can be billed with all the Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance. 0360 Operating Room Services - General Classification CPT/HCPCS Codes Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and CMS require the use of short CPT descriptors in policies published on the Web. Note: Use CPT code 43659 when BOTH the gastric band and subcutaneous port components were removed AND replaced. Note: Use CPT code 43843 to identify open-sleeve gastrectomy. Note: Use CPT code 43999 to identify: 1) laparoscopic vertical-banded gastroplasty; and 2) open adjustable gastric banding. Non-covered services: 43842, 43843 and 43999. (Please note 43999 can be used for LSG between 6/27/2012 and 10/1/2012 per CR 8028. However, all other use will be denied as noted above. Use of this code will result in the claim being suspended for review.) Medicare coverage for replacement of gastric restrictive devices is limited (see Indications and Limitations section regarding repeat bariatric surgical procedures). Use of CPT code 43659 to report removal and replacement of both components is covered with one of the following diagnoses: 996.59, 996.60 or 996.70.

43644 Lap gastric bypass/roux-en-y 43645 Lap gastr bypass incl smll i 43659 Laparoscope proc stom 43770 Lap place gastr adj device 43771 Lap revise gastr adj device 43772 Lap rmvl gastr adj device 43773 Lap replace gastr adj device 43774 Lap rmvl gastr adj all parts 43775 Lap sleeve gastrectomy 43842 V-band gastroplasty 43843 Gastroplasty w/o v-band 43845 Gastroplasty duodenal switch 43846 Gastric bypass for obesity 43847 Gastric bypass incl small i 43848 Revision gastroplasty 43886 Revise gastric port open 43887 Remove gastric port open 43888 Change gastric port open 43999 Stomach surgery procedure ICD-9 Codes that Support Medical Necessity Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims. The CPT/HCPCS codes included in this LCD will be subjected to procedure to diagnosis editing. Coverage for selected bariatric surgery procedures on patients who meet national and local coverage criteria set forth in this LCD requires reporting three appropriate diagnoses. Report the primary diagnosis as 278.01 (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. Medicare is establishing the following limited coverage for CPT/HCPCS codes 43644, 43645, 43770, 43775, 43845, 43846, 43847 and 43887: Table 1: Secondary Diagnoses Covered for: 250.00 250.02 250.10 250.12 250.20 250.22 250.30 250.32 250.40 250.42 250.50 250.52 250.60 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.62 250.70 250.72 250.80 250.82 250.90 250.92 272.0-272.4 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED PURE HYPERCHOLESTEROLEMIA - OTHER AND UNSPECIFIED HYPERLIPIDEMIA 278.03 OBESITY HYPOVENTILATION SYNDROME 327.23 OBSTRUCTIVE SLEEP APNEA (ADULT) (PEDIATRIC) 327.26 SLEEP RELATED HYPOVENTILATION/HYPOXEMIA IN CONDITIONS CLASSIFIABLE ELSEWHERE 348.2 BENIGN INTRACRANIAL HYPERTENSION 401.1 BENIGN ESSENTIAL HYPERTENSION 416.8 OTHER CHRONIC PULMONARY HEART DISEASES 425.8 CARDIOMYOPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE 530.11* REFLUX ESOPHAGITIS 571.8 OTHER CHRONIC NONALCOHOLIC LIVER DISEASE 715.15-715.17 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING PELVIC REGION AND THIGH - OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING ANKLE AND FOOT 715.25 - OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING

715.27 PELVIC REGION AND THIGH - OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING ANKLE AND FOOT 715.35-715.37 715.89 722.52 722.73 724.02-724.03 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING PELVIC REGION AND THIGH - OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING ANKLE AND FOOT OSTEOARTHROSIS INVOLVING OR WITH MULTIPLE SITES BUT NOT SPECIFIED AS GENERALIZED DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC INTERVERTEBRAL DISC DISORDER WITH MYELOPATHY LUMBAR REGION SPINAL STENOSIS, LUMBAR REGION, WITHOUT NEUROGENIC CLAUDICATION - SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION *Note: 530.11 This diagnosis is not covered for CPT code 43770. Table 2: Tertiary Diagnoses Covered for: V85.35 BODY MASS INDEX 35.0-35.9, ADULT V85.36 BODY MASS INDEX 36.0-36.9, ADULT V85.37 BODY MASS INDEX 37.0-37.9, ADULT V85.38 BODY MASS INDEX 38.0-38.9, ADULT V85.39 BODY MASS INDEX 39.0-39.9, ADULT V85.41 BODY MASS INDEX 40.0-44.9, ADULT V85.42 BODY MASS INDEX 45.0-49.9, ADULT V85.43 BODY MASS INDEX 50.0-59.9, ADULT V85.44 BODY MASS INDEX 60.0-69.9, ADULT V85.45 BODY MASS INDEX 70 AND OVER, 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. Medicare is establishing the following limited coverage for CPT/HCPCS codes 43772 and 43774: Covered for: 996.59 996.60 996.70 MECHANICAL COMPLICATION OF OTHER IMPLANT AND INTERNAL DEVICE NOT ELSEWHERE CLASSIFIED INFECTION AND INFLAMMATORY REACTION DUE TO UNSPECIFIED DEVICE IMPLANT AND GRAFT OTHER COMPLICATIONS DUE TO UNSPECIFIED DEVICE IMPLANT AND GRAFT Diagnoses that Support Medical Necessity N/A ICD-9 Codes that DO NOT Support Medical Necessity N/A ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation Diagnoses that DO NOT Support Medical Necessity All diagnoses not listed in the ICD-9 Codes That Support Medical Necessity section of this LCD. Go to Top Other Information Documentation Requirements Documentation supporting medical necessity should be legible, maintained in the patient s medical record and made available to Medicare upon request. Each claim must be submitted with ICD-9-CM codes that reflect the condition of the patient and indicate the reason(s) for which the service was performed. The medical record must substantiate presence and severity of associated organic diseases requiring the treatment of obesity documented through appropriate physiologic testing and/or imaging. The patient s medical record must include documentation of all required preoperative and postoperative evaluations and interventions and all other applicable coverage provisions required under both this LCD and prevailing National Coverage Determinations (NCDs).

Appendices N/A Utilization Guidelines Repeat bariatric surgery is generally not reasonable and necessary. Medicare does not provide prior authorization for these services. Claims for more than one bariatric surgical procedure most likely will create a denial. However, in the appeals process, medical documentation may be submitted for review and the service may potentially be covered when clinical circumstances demonstrate reasonability and necessity. Appropriate ABN and modifiers should be appended to any services potentially to be denied. Notice: This LCD imposes utilization guideline limitations. Despite Medicare's allowing up to these maximums, each patient s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services. Sources of Information and Basis for Decision Other Contractor Local Coverage Determinations Bariatric Surgical Management of Morbid Obesity, TrailBlazer LCD, (00400) L23957, (00900) L23959. Novitas Solutions, Inc. JH Local Coverage Determination (LCD) Consolidation Narrative Justification Most Clinically Appropriate LCD LCDs Compared: L26758, Bariatric Surgical Management of Morbid Obesity, TrailBlazer, CO, NM, OK, TX A/B CMD Rationale: This is an LCD which represents a substantive area of Medicare program vulnerability importance, and, as such, this single MAC LCD should be extended to all of JH. In addition, this current LCD has a robust procedure-to-diagnosis coding edit structure, which is well-correlated with text on clinical indications/limitations, and the LCD is also formatted to be Medical Review-friendly in the event of necessary post-pay reviews. L26758 is the most clinically appropriate LCD. Advisory Committee Meeting Notes Start Date of Comment Period N/A End Date of Comment Period: N/A Start Date of Notice Period 06/28/2012

Go to Top Revision History Revision History Number 7 Revision History Explanation Date Policy # Description 12/21/2012 (Revision History #7) 12/21/2012 (Revision History #6) 11/19/2012 (Revision History #5) 10/29/2012 (Revision History #4) 10/22/2012 (Revision History #3) 08/20/2012 (Revision History #2) 08/13/2012 (Revision History #1) LCD revised to implement CR 8028. Previous LCD revision released on 12/21/2012 was incorrect. LCD revision effective for dates of service on and after 06/27/2012. LCD revised effective for dates of service on and after 06/27/2012 to allow limited coverage of LSG per CMS CR 8028. Per CMS Change Request (CR) 7812, this LCD has been updated with the original effective date of 11/19/2012 to add the Novitas Jurisdiction H Part B MAC Contract Numbers 04112, 04212, 04312, and 04412 for Colorado Part B, New Mexico Part B, Oklahoma Part B, Texas Part B, Indian Health Service (IHS)/Tribal/Urban Indian Providers Part B, and Veterans Affairs (VA) Part B. No other changes were made to this LCD. Per CMS Change Request (CR) 7812, this LCD has been updated with the original effective date of 10/29/2012 to add the Novitas Jurisdiction H Part A MAC Contract Numbers 04911, 04111, 04211, 04311, and 04411 for Colorado Part A, New Mexico Part A, Oklahoma Part A, Texas Part A, Indian Health Service (IHS)/Tribal/Urban Indian Providers Part A, and Veterans Affairs (VA) Part A. No other changes were made to this LCD. LCD original effective date of 10/22/2012 for Mississippi Part B. LCD original effective date of 08/20/2012 for Arkansas Part A, Louisiana Part A and Mississippi Part A. LCD original effective date of 08/13/2012 for Arkansas Part B and Louisiana Part B. LCD posted for notice on 06/28/2012. Reason for Change CMS Requirement Related Documents This LCD has no Related Documents. LCD Attachments There are no attachments for this LCD.