BlueCross BlueShield of Tennessee Medical Policy Manual

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:

Surgery for morbid obesity, termed bariatric surgery, falls into the following categories:

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

MEDICAL APPROPRIATENESS

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.

ADDITIONAL INFORMATION

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:

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.

Alami, R. S., Morton, J. M., Schuster, R., Lie, J., Sanchez, B. R., Peters, A., et al. (2007). Is there a benefit to preoperative weight loss in gastric bypass patients? A prospective randomized trial. Surgery for Obesity and Related Diseases, 3 (2), 141-145. Abstract retrieved October 31, 2007 from PubMed database.

Ali, M. R., Baucom-Pro, S., Broderick-Villa, G. A., Campbell, J. B., Rasmussen, J. J., Weston, A. N., et al. (2007). Weight loss before gastric bypass: Feasibility and effect on postoperative weight loss and weight loss maintenance. Surgery for Obesity and Related Diseases, 3 (5) 515-520. Abstract retrieved October 31, 2007 from PubMed database.

American Association of Clinical Endocrinologist. (1998). Clinical Guidelines On-Line Index: Obesity Position Statement©. Retrieved December 17, 2001 from http://www.aace.com/pub/pdf/guidelines/obesityguide.pdf.  (250 articles and/or guidelines reviewed)

American College of Physicians. (2005). Meta-Analysis: Surgical treatment of obesity. Retrieved September 26, 2007 from http://www.acponline.org/clinical/guidelines/#rpg. (202 articles and/or guidelines reviewed)

American College of Physicians. (2005, April). Pharmacologic and surgical management of obesity in primary care: A clinical practice guideline from the American College of Physicians. Retrieved August 10, 2005 from http://www.acponline.org/clinical/guidelines/. (43 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.   

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)

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. (2:2008). Surgery for morbid obesity (7.01.47). Retrieved January 5 2009 from BlueWeb. (53 articles and/or guidelines reviewed)

BlueCross BlueShield of Tennessee network physicians. September 2007.

Complete Guide to Medicare Coverage Issues [Computer software]. (2008, November). Bariatric surgery for treatment of morbid obesity (NCD 100.1, p. 2-45). The Ingenix Complete Guide to Medicare Coverage Issues.

Complete Guide to Medicare Coverage Issues [Computer software]. (2008, November). Gastric balloon for treatment of obesity – Not Covered (NCD 100.11, p. 2-48). The Ingenix Complete Guide to Medicare Coverage Issues.

Complete Guide to Medicare Coverage Issues [Computer software]. (2008, November). Intestinal by-pass surgery – Not covered (NCD 100.8, p. 2-47). The Ingenix Complete Guide to Medicare Coverage Issues.

Complete Guide to Medicare Coverage Issues [Computer software]. (2008, November). Treatment of obesity (NCD 40.5, p. 2-33). The Ingenix Complete Guide to Medicare Coverage Issues.

Dixon, J. B., O’Brien, P. E., Playfair, J., Chapman, L., Schachter, L. M., Skinner, S., et al. (2007). Adjustable gastric banding and conventional therapy for type 2 diabetes. Journal of American Medical Association, 299 (3), 316-232.

ECRI Institute. Health Technology Assessment Information Service. Comprehensive Technology Assessment. (2004, September). Bariatric surgery for obesity. Retrieved August 29, 2005 from ECRI Institute.  (224 articles and/or guidelines reviewed)

ECRI Institute. Health Technology Assessment Information Service. Health Technology Assessment. (2007, August). Bariatric surgery in pediatric patients. Retrieved September 26, 2007 from ECRI institute.  (137 articles and/or guidelines reviewed)

ECRI Institute. Health Technology Assessment Information Service. Windows on Medical Technology. (2005, May). Laparoscopic bariatric surgery for morbid obesity. Retrieved June 29, 2005 from ECRI Institute. (116 articles and/or guidelines reviewed)

Flum, D. l., Salem, L., Elrod, J., A., Dellinger, E. P., Cheadle, A., & Chan, L. (2005). Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. Journal of American Medical Association, 294 (15), 1903-1908.

Hayes. Medical Technology Directory. (2007, June). Laparoscopic bariatric surgery: Roux-en-Y gastric bypass, vertical banded gastroplasty, and adjustable gastric banding. Retrieved July 6, 2007 from www.Hayesinc.com/subscribers.  (93 articles and/or guidelines reviewed)

Hayes. Medical Technology Directory. (2007, June). Malabsorptive bariatric surgery: Open and laparoscopic biliopancreatic diversion. Retrieved July 6, 2007 from www.Hayesinc.com/subscribers.  (94 articles and/or guidelines reviewed)

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.

Mechanick, J.I., Kushner, R.F., Sugerman, H.J., Gonzalez-Campoy, M., Collazo-Clavell, M.L., Guven, S., et al. (2008). American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Surgery for Obesity and Related Diseases, 4 (5 Suppl), S109-S184.

National Guideline Clearinghouse. (2002, September). American Gastroenterological Association medical position statement on obesity. Retrieved August 24, 2005 from http://www.guideline.gov/summary/pdf.aspx?doc_id=3490&stat=1&string=bariatric+AND+surgery.

National Institute of Health. (1998, September). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Retrieved January 29, 2004 from http://www.nhlbi.nih.gov/guidelines/obesity/e_txtbk/index.htm.

National Institute of Health. (2004, December). WIN: Gastrointestinal surgery for severe obesity. Retrieved October 16, 2007 from http://win.niddk.nih.gov/publications/gastric.htm.

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.

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.

Sjostrom, L., Narbro, K., Sjostrom, C. D., Karason, K., Larsson, B., Wedel, H., et al. (2007). Effects of bariatric surgery on mortality in Swedish obese subjects. NEJM, 357 (8), 741-752.

Still, C., Benotti, P., Wood, G., Gerhard, G., Petrick, A., Reed, M., et al. (2007). Outcomes of preoperative weight loss in high-risk patients undergoing gastric bypass surgery. Archives of Surgery, 142 (10), 994-998.

The Technology Evaluation Center. (2003, September). Special report: The relationship between weight loss and changes in morbidity following bariatric surgery for morbid obesity. (Vol. 18, No. 9). Chicago: BlueCross BlueShield Association. (54 articles and/or guidelines reviewed)

The Technology Evaluation Center. (2006, February). Laparoscopic gastric bypass surgery for morbid obesity. (Vol. 20, No. 15). Chicago: BlueCross BlueShield Association. (148 articles and/or guidelines reviewed)

The Technology Evaluation Center. (2007, February). Laparoscopic adjustable gastric banding for morbid obesity. (Vol. 21, No. 13). Chicago: BlueCross BlueShield Association. (119 articles and/or guidelines reviewed)

U. S. Food and Drug Administration. (2001, June). Center for Devices and Radiological Health. Lap-Band® adjustable gastric banding (LAGB®) system P000008. Retrieved December 17, 2001from http://www.fda.gov/cdrh/pdf/p000008.html.

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.

ORIGINAL EFFECTIVE DATE:  12/10/1980

MOST RECENT REVIEW DATE:  8/21/2009

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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