Bariatric Surgery for Morbid Obesity
Does not apply to TennCare, please refer to the TennCare policy.
Does not apply to the State of TN 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 has empirically been defined as more than 100 lbs. (45.4 kg) or 100% over ideal body weight. The American Association of Clinical Endocrinologists, The Obesity Society and American Society for Metabolic & Bariatric Surgery (AACE/TOS/ASMB) guideline defines obesity as a body mass index (BMI; weight in kg/[height in meters]2) greater than or equal to 30 kg/m2 in an overall classification as follows:
The healthy range of weight is 18.5 to 24.9 kg/m2
Overweight is 25 to 29.9 kg/m2
Class I obesity is 30 to 34.9 kg/m2
Class 2 obesity is 35 to 39.9 kg/m2
Class 3 obesity is greater than or equal to 40 kg/m2
Some groups further subcategorize this last entity into:
Class 4 obesity (superobesity) as 50 to 59.9 kg/m2
Class 5 (super-superobesity) as greater than 60 kg/m2.
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
It is highly recommended that physicians utilize the Pre-Bariatric Surgery Evaluation Tool in order to simplify and speed up the pre-bariatric surgery review and approval process.
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.)
Sleeve gastrectomy, on its own, or in combination with malabsorptive procedures, for the treatment of morbid obesity is considered investigational.
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 ANY ONE of the following criteria are met:
An individual who has had a prior bariatric surgical procedure and is requesting / requiring a revision, alteration or reversal must have a related medical or surgical complication of that procedure that is documented by the physician
ALL of the following:
The Pre-Bariatric Surgery Evaluation Tool must be completed and submitted with the request for authorization
The attending physician must submit evidence that the attempt at conservative management was within two (2) years prior to the planned surgery
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
The attending physician must be someone other than the operating surgeon and his/her associates
The individual has a diagnosis of morbid obesity that has persisted for at least five (5) years, and is defined as either:
Class 3 obesity with a BMI greater than or equal to 40 kg/m2
Class 2 obesity with a BMI 35 to 39.9 kg/m2 in conjunction with any of the following obesity-related comorbidities that will reduce the individual’s life expectancy:
Coronary artery disease
Type 2 diabetes mellitus
Obstructive sleep apnea
Three or more of the following cardiac risk factors:
Hypertension (BP greater than 140 mmHg systolic and/or 90 mmHg diastolic)
High density lipoprotein (HDL) less than 40 mg/dL
Low density lipoprotein (LDL) greater than 100 mg/dL
Impaired glucose tolerance (2-hour blood glucose greater than 140 mg/dL on an oral glucose tolerance test)
Family history of early cardiovascular disease in first degree relative (myocardial infarction at fifty-five 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
Interview/evaluation results
Minnesota Multiphasic Personality Inventory (MMPI 2)
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.
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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.
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ORIGINAL EFFECTIVE DATE: 12/10/1980
MOST RECENT REVIEW DATE: 8/21/2009
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