Bariatric Surgery for Morbid Obesity
Does not apply to TennCare, please refer to the TennCare policy.
Does not apply to the State of Tennessee Member Contract.
DESCRIPTION
Morbid obesity is a condition of persistent and uncontrollable weight gain that constitutes a present or potential threat to life. Morbid obesity is defined as a body mass index (BMI) greater than 40 kg/m2 or BMI greater than or equal to 35 kg/m2 with obesity-related co-morbidities at high risk of mortality and morbidity. This is characterized by a weight, which is at least 100 pounds over the ideal weight, or twice the ideal weight for frame, age, height and sex as specified in the latest Metropolitan Life Height and Weight table.
The first treatment of morbid obesity is dietary and lifestyle changes. Although this strategy may be effective in some individuals, only a few morbidly obese individuals can reduce and control weight through diet and exercise. The majority of individuals find it difficult to comply with these lifestyle modifications on a long-term basis.
Surgery for morbid obesity, termed bariatric surgery, falls into the following categories:
Gastric restrictive surgical procedures create a small gastric pouch, resulting in weight loss for early satiety and decreased dietary intake. The decreased capacity of the stomach reduces the volume of food an individual consumes before feeling full.
Combination surgical procedures include decreasing the stomach capacity and bypassing part of the digestive tract. They combine food malabsorption and the volume of food an individual can consume.
Malabsorptive surgical procedures bypass a section of the small intestines. Weight loss results from intestinal malabsorption without dietary modification.
See Additional Information for brief descriptions of the various bariatric procedures.
Refer to the Pre-Bariatric Surgery Evaluation Tool
POLICY
Bariatric surgery, using a laparoscopic or open procedure, for the treatment of morbid obesity is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
MEDICAL APPROPRIATENESS
Bariatric surgery, for the treatment of morbidly obese individuals 18 years or older, is considered medically appropriate if all of the following criteria are met:
The Pre-Bariatric Surgery Evaluation Tool must be completed and submitted with the request for authorization; and
The attending physician must submit evidence that the attempt at conservative management was within two (2) years prior to the planned surgery; and
The attending physician must submit records that the individual has successfully lost 10% of initial body weight prior to the date that the authorization is requested; and
The attending physician must be someone other than the operating surgeon and his/her associates; and
The individual has a diagnosis of morbid obesity that has persisted for at least five (5) years, and is defined as either:
More than 45 kg (100 pounds) over the ideal weight or at least twice the ideal weight. The ideal body weight can be determined from the Metropolitan Life Height and Weight table; or
BMI is greater than or equal to 40 kg/m2; or
BMI is greater than or equal to 35 kg/m2 in conjunction with any of the following obesity-related co-morbidities that will reduce the individual’s life expectancy:
Coronary artery disease; or
Type 2 diabetes mellitus; or
Obstructive sleep apnea; or
Three or more of the following cardiac risk factors:
Hypertension (BP greater than 140 mmHg systolic and/or 90 mmHg diastolic); or
High density lipoprotein (HDL) less than 40 mg/dL; or
Low density lipoprotein (LDL) greater than 100 mg/dL; or
Impaired glucose tolerance (2-hour blood glucose greater than 140 mg/dL on an oral glucose tolerance test); or
Family history of early cardiovascular disease in first degree relative (myocardial infarction at fifty years of age or younger in a male relative or at sixty-five years of age or younger in a female relative).
Psychiatrist/Psychologist must submit all of the following:
Documentation of the individual’s willingness to comply with both the pre and postoperative treatment plans; and
Interview/evaluation results; and
Minnesota Multiphasic Personality Inventory (MMPI 2); and
The Eating Disorder Inventory (EDI-2) or the Eating Attitudes Test (EAT-26)
NOTE: If any of the above (Interview/evaluation, MMPI 2, EDI-2 or EAT-26) provides a suggestion of cognitive slippage or psychosis, a predictive test (e.g., Thematic Apperception Test (TAT) or the Rorschach test) is required.
The cost of bariatric surgery for the treatment of morbid obesity may or may not be covered by insurance.
Well-designed clinical trials, addressing other procedures (e.g., cholecystectomy, liver biopsy) performed at the same time as bariatric surgery, are not available. As always, each separate procedure must independently be determined to be clinically appropriate to be considered medically necessary.
National Institutes of Health Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: Evidence Report addresses the initial goal of weight loss as, “there is strong and consistent evidence from randomized trials that overweight and obese patients in well-designed programs can achieve a weight loss of as much as 10 percent of baseline weight.” They also report “randomized trials suggest that weight loss at the rate of 1 to 2 lb/week (calorie deficit of 500 to 1,000 kcal/day) commonly occurs for up to 6 months.”
American Society for Bariatric Surgery Guidelines for Laparoscopic and Conventional Surgical Treatment of Morbid Obesity addresses peri-operative and long-term management considerations. The guidelines state, “The overall care of patients undergoing bariatric surgery (weight reduction surgery) requires programs which address both perioperative care and long-term management….Patients should have a clear understanding of expected benefits, risk, and long term consequences of surgical treatment…Patients require appropriate lifelong follow-up with nutritional counseling and biochemical surveillance. Surgeons need to be aware of the needs of severely obese patients in terms of facilities, supplemental equipment, staff and procedures, and should plan the personal time, specialized staff and/or multi-disciplinary referral system as required. This multi-disciplinary approach includes medical management of co-morbidities, dietary instruction, exercise training, specialized nursing care and psychological assistance as needed. Post-operative management of co-morbidities should be directed by the practitioner familiar with the operation performed and the changes created.”
Brief description of the various bariatric procedures:
Vertical banded gastroplasty (VBG): Restricts the size of the stomach using a stapling technique. There is no rearrangement of the intestinal anatomy.
Gastric bypass using the Roux-en-Y anastomosis: Restricts the size of the stomach by stapling shut 90% of the lower stomach. The proximal intestinal anatomy is re-arranged, thereby bypassing the duodenum.
Gastric banding: Involves placing a gastric band around the outside of the stomach. The stomach is not entered.
Mini gastric bypass: Uses the laparoscopic approach, the stomach is segmented, similar to a traditional gastric bypass. Instead of creating a Roux-en-Y anastomosis, the jejunum is anastomosed incontinuity directly to the stomach, similar to a Billroth II procedure. The unique aspect of the procedure is not based on the laparoscopic approach, but rather the type of anastomosis used.
Biliopancreatic bypass procedure (i.e., Scopinaro procedure): Consist of subtotal gastrectomy using a long Roux-en-Y procedure to divert the biliopancreatic juices into the distal ileum.
Biliopancreatic bypass with duodenal switch: It is essentially a variant of the biliopancreatic bypass. Instead of performing a distal gastrectomy, a “sleeve” gastrectomy is performed along the vertical axis of the stomach. The sleeve gastrectomy decreases the volume of the stomach and the parietal cell mass.
Sleeve gastrectomy: A form of unbanded gastroplasty involving subtotal gastric resection for creation of a long lesser curve-based gastric conduit. It has been utilized as a first-stage bariatric procedure to reduce surgical risk in high-risk patients by induction of weight loss, to be then followed by subsequent surgical procedures to convert the sleeve gastrectomy to an intestinal bypass.
SOURCES
Adams, T. D., Gress, R. E., Sherman, C. S., Halverson, R. C., Simper, S. C., Rosamond, W. D., et al. (2007). Long-term mortality after gastric bypass surgery. NEJM. 357 (8), 753-761.
Agency for Healthcare Research and Quality. (2003). Evidence Report/Technology Assessment (21): Screening and interventions for overweight and obesity in adults. Retrieved November 29, 2004 from http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat3.chapter.29156.
Agency for Healthcare Research and Quality. (2004). Evidence Report/Technology Assessment (103): Pharmacological and surgical treatment of obesity. Retrieved November 29, 2004 from http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1a.chapter.19289.
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American Society for Metabolic and Bariatric Surgery. (2007, June). ASMBS Position Statement on sleeve gastrectomy as a bariatric procedure. Retrieved September 26, 2007 from http://www.asbs.org/Newsite07/resources/sleeve_statement.pdf. (17 articles and/or guidelines reviewed)
American Society for Metabolic and Bariatric Surgery. (2000, May). SAGES / ASBS guidelines for laparoscopic and conventional surgical treatment of morbid obesity. Retrieved August 21, 2003 from http://www.asbs.org/html/lab_guidelines.html. (20 articles and/or guidelines reviewed)
American Society for Metabolic and Bariatric Surgery. (2004). Consensus Conference Statement Bariatric Surgery for Morbid Obesity: Health implications for patients, health professional, and third party payers. Retrieved November 1, 2005 from http://www.asbs.org/html/pdf/2004_ASBS_Consensus_Conference_Statement.pdf.
American Society for Metabolic and Bariatric Surgery. (2004, October). Suggestions for the pre-surgical assessment of bariatric surgery candidates. Retrieved November 1, 2005 from http://www.asbs.org/html/pdf/PsychPreSurgicalAssessment.pdf.
Averbukh, Y., Heshka, S., El-Shoreya, H., Flancbaum, L., Geliebter, A., Kamel, S., et al. (2003). Depression score predicts weight loss following Roux-en-Y gastric bypass. Obesity Surgery, 13 (6), 833-836. Abstract retrieved September 7, 2005 from PubMed database.
BlueCross BlueShield Association. Medical Policy Reference Manual. (5:2006). Surgery for morbid obesity (7.01.47). Retrieved July 31, 2007 from BlueWeb. (43 articles and/or guidelines reviewed)
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Complete Guide to Medicare Coverage Issues [Computer software]. (2007, April). Bariatric surgery for treatment of morbid obesity (NCD 100.1, p. 2-45). St. Anthony Publishing.
Complete Guide to Medicare Coverage Issues [Computer software]. (2007, April). Gastric balloon for treatment of obesity – Not Covered (NCD 100.11, p. 2-48). St. Anthony Publishing.
Complete Guide to Medicare Coverage Issues [Computer software]. (2007, April). Intestinal by-pass surgery – Not covered (NCD 100.8, p. 2-47). St. Anthony Publishing.
Complete Guide to Medicare Coverage Issues [Computer software]. (2007, April). Treatment of obesity (NCD 40.5, p. 2-33). St. Anthony Publishing.
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Hayes. Medical Technology Directory. (2007, June). Open malabsorptive bariatric surgery: Roux-en-Y gastric bypass. Retrieved July 6, 2007 from www.Hayesinc.com/subscribers. (110 articles and/or guidelines reviewed)
Hayes. Medical Technology Directory. (2007, June). Open restrictive bariatric surgery: Gastroplasty and gastric banding. Retrieved July 6, 2007 from www.Hayesinc.com/subscribers. (85 articles and/or guidelines reviewed)
Hayes. Medical Technology Directory. (2007, June). Pediatric bariatric surgery for morbid obesity. Retrieved July 6, 2007 from www.Hayesinc/com/subscribers. (81 articles and/or guidelines reviewed)
Heshka, S., Anderson, J. W., Atkinson, R. L., Greenway, F. L., Hill, J. O., Phinney, S. D., et al. (2003). Weight loss with self-help compared with a structured commercial program: A randomized trial. JAMA, 289 (14), 1792-1798. Abstract retrieved February 5, 2004 from PubMed database.
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National Institute of Health. (2007, January). Longitudinal assessment of bariatric surgery (LABS). Retrieved November 1, 2007 from http://win.niddk.nih.gov/publications/labs.htm.
Peterli, R., Donadini, A., Peters, T., Ackermann, C., & Tondelli, P. (2002). Re-operations following laparoscopic adjustable gastric banding. Obesity Surgery, 12 (6), 851-856. Abstract retrieved March 4, 2003 from PubMed database.
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Riverbend Government Benefits Administrator. Local Coverage Determinations (LCDs). (November, 2004). LMPR for bariatric surgery (L13093). Retrieved October 30, 2007 from http://www.rgbagov.com/publications/lcd/lcd-files/100-03c.html.
Scott, D. J., Villegas, T. L, Sims, E. C., Hamilton, D. A., Provost, D., & Jones, B. (2003). Intraoperative ultrasound and prophylactic ursodiol for gallstone prevention following laparoscopic gastric bypass. Surgical Endoscopy, 17 (11), 1796-1802.
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U.S. Department of Health & Human Services. Centers for Medicare & Medicaid Services. LMPRs/LCDs for CIGNA Government Services. (2007, January). LCD for bariatric surgery (surgical management of morbid obesity) (L24057). Retrieved October 30, 2007 from http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=24057&lcd_version=5&show=all
U.S. Food and Drug Administration. (2007, September). Center for Devices and Radiological Health. Realize™ adjustable gastric band - P070009. Retrieved October 30, 2007 from http://www.fda.gov/cdrh/pdf7/p070009.html.
Wadden, T. A., Berkowitz, R. I., Womble, L. G., Sarwer, D. B., Phelan, S., Cato, R. K., et al. (2005). Randomized trial of lifestyle modification and pharmacotherapy for obesity. The New England Journal of Medicine, 353 (20), 2111-2120.
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EFFECTIVE DATE |
2/28/2008 |
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ID_BT
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