BlueCross BlueShield of Tennessee Medical Policy Manual

Bariatric Surgery

Does not apply to the State of TN Member Contract.
Does not apply to CoverKids.

DESCRIPTION

Obesity has a multifactorial cause that includes genetic, environmental, dietary as well as cultural and psychosocial aspects. When obesity reaches the level of ‘morbid obesity’, it is associated with adverse effects on almost all the organ systems and can dramatically decrease both life expectancy and quality of life. Therefore, consideration should also be given to the individual candidate requesting this elective procedure. The 2013 guidelines published by the by the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic & Bariatric Surgery recommends all individuals considering bariatric surgery should undergo a pre-operative evaluation that includes: a comprehensive medical history, psychosocial history, physical exam, and appropriate testing to assess surgical risk.

Bariatric surgery is a treatment for extreme obesity in individuals who fail to lose weight with medical therapy and/or conservative measures. Weight loss surgery techniques fall into the following general categories:

Description of bariatric procedures:

Biliopancreatic bypass procedure (BPB) (i.e., Scopinaro procedure): Consist of subtotal gastrectomy using a long Roux-en-Y procedure to divert the biliopancreatic juices into the distal ileum. Because of the high incidence of cholelithiasis associated with the procedure, patients typically undergo an associated cholecystectomy.

Biliopancreatic bypass with duodenal switch (BPB-DS):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. This approach preserves the pylorus and initial segment of the duodenum, which is then anastomosed to a segment of the ileum, similar to the biliopancreatic bypass, to create the alimentary limb.

Long-Limb Gastric Bypass: the stomach is divided with a long segment of the jejunum (instead of ileum) anastomosed to the proximal gastric stump, creating the alimentary limb. The remaining pancreaticobiliary limb, consisting of stomach remnant, duodenum, and length of proximal jejunum, is then anastomosed to the ileum, creating a common limb of variable length in which the ingested food mixes with the pancreaticobiliary juices.

Gastric bypass using the Roux-en-Y anastomosis (RYGB):Restricts the size of the stomach by stapling shut a large portion (up to 90%) of the lower stomach and performing a gastrojejunal anastomosis, thereby bypassing the duodenum. This can be done as a laparoscopic or open procedure.

Gastric banding (LAGB): Involves placing a gastric band around the outside of the stomach. The band is attached to a reservoir where saline can be injected to alter the diameter of the band thereby limiting the stoma in the stomach and systematically decreasing the capacity of the stomach. Complications include slippage of the external band or band erosion through the gastric wall.

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.

Minimally Invasive Procedures: (e.g., Implantable sleeve and gastric plication procedures such as laparoscopic greater curvature plication or total vertical gastric plication) are addressed within a separate medical policy linked beneath the policy statements.

Sleeve gastrectomy (LSG): A form of unbanded gastroplasty; the greater curvature of the stomach is resected from the angle of His to the distal antrum, resulting in a stomach remnant shaped like a tube or sleeve. Sleeve gastrectomy can be performed as an open or laparoscopic procedure. It can also be utilized as a first-stage bariatric procedure to reduce surgical risk in high-risk patients by induction of weight loss, and followed by subsequent surgical procedures to convert the sleeve gastrectomy to an intestinal bypass.

Single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S): A small gastric sleeve is created, by sectioning the greater curvature of the stomach, such as in the Sleeve technique. A duodenum-intestinal anastomosis is performed, near ileocecal valve.

Vertical banded gastroplasty (VBG):Restricts the size of the stomach using a stapling technique. The stomach is segmented along its vertical axis. To create a durable reinforced and rate-limiting stoma at the distal end of the pouch, a plug of stomach is removed, and a propylene collar is placed through this hole and then stapled to itself. There is no rearrangement of the intestinal anatomy.

This policy does not address all minimally invasive techniques for weight loss surgery [e.g. implantable sleeve, Restorative Obesity Surgery Endoluminal (ROSE)]. Please see the BCBST policies specifically addressing these techniques (see hyperlinks below).

It is highly recommended that physicians utilize the Bariatric Surgery Precertification Request Form in order to simplify and speed up the pre-bariatric surgery review process.

Refer to the Bariatric Surgery Precertification Request Form

POLICY

See also:  

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

This medical policy does not apply to the State of TN Member Contract.

This medical policy does not apply to CoverKids.

ADDITIONAL INFORMATION

The cost of bariatric surgery for the treatment of morbid obesity may or may not be covered by insurance.

The American Association of Clinical Endocrinologists, The Obesity Society and American Society for Metabolic & Bariatric Surgery (AACE/TOS/ASMB) guideline classifies obesity by 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:

Well-designed clinical trials, addressing other procedures (e.g., cholecystectomy, liver biopsy) performed at the same time as bariatric surgery, are not available. Well-designed prospective studies are emerging to better define the place for adolescent bariatric surgery. As always, each separate procedure must independently be determined to be clinically appropriate to be considered medically necessary.

SOURCES

Agency for Healthcare Research and Quality. Department of Health & Human Services. (2013, June) Bariatric surgery and nonsurgical therapy in adults with metabolic conditions and a body mass index of 30.0 to 34.9 kg/m2 Comparative Effectiveness Review Number 82. Received October 21, 2015 from: www.ahrq.gov.

American Association of Clinical Endocrinologists, the Obesity Society and the American Society for Metabolic & Bariatric Surgery (2013) Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient-2013 Update. Surgery for Obesity and Related Diseases 9 (2013) 159-191.

American College of Cardiology/American Heart Association/The Obesity Society (2013) AHA/ACC/TOS Guideline for the management of overweight and obesity in adults. Journal of American College of Cardiology, 2013 (epub).

American Society for Metabolic and Bariatric Surgery. (2011, September) ASMBS pediatric committee best practice guideline Surgery for Obesity and Related Diseases, 8 (1), 1-7.s.

American Society for Metabolic and Bariatric Surgery. (2012, March) Updated position statement on sleeve gastrectomy as a bariatric procedure. Surgery for Obesity and Related Diseases. 8 (2012) e21-e26.

American Society of Bariatric Surgery. (2004; reviewed 2011). Suggestions for the pre-surgical psychological assessment of bariatric surgery candidates. Retrieved January 20, 2014 from http://asmbs.org.

Aminian, A., Brethauer, S., Sharafkhah, M., and Schauer, P. (2015, July) Development of a sleeve gastrectomy risk calculator. Surgery for Obesity Related Diseases. 2015 Jul-Aug;11(4):758-64. Abstract retrieved December 6, 2016 from PubMed database.

Benotti, P., Still, C., Wood, G., Akmal, Y., King, H., El Arousy, H., et al. (2009). Preoperative weight loss before bariatric surgery. Archives of Surgery, 144 (12), 1150 - 1155. (Level 3 evidence)

BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2016). Bariatric surgery (7.01.47). Retrieved February 18, 2016 from: BlueWeb. (134 articles and/or guidelines reviewed)

California Technology Assessment Forum. Institute for Clinical and Economic Review (August, 2015) Controversies in obesity management. Received October 20, 2015 from: http://www.ctaf.org (167 articles and/or guidelines reviewed) 

Center for Medicare and Medicaid Services. CMS.gov. (December, 2013) National Coverage Determination (NCD) for Bariatric surgery for the treatment of morbid obesity (100.1) December 6, 2016 from: www.cms.gov.

Center for Medicare and Medicaid Services. CMS.gov. (October, 2015) Local Coverage Determination (LCD) Laparoscopic sleeve gastrectomy for severe obesity (L34576) Retrieved February 18, 2016 from: www.cms.gov.

Chang, S., Stoll, C., Song, J., Varela, E., Eagon, C., and Colditz, G. (2014, March) Bariatric surgery: an updated systematic review and metaanalysis, 2003–2012. Journal of the American Medical Association. 149(3):275-287. (Level 1 evidence)

Chung, F., Abdullah, H., and Liao, P. (2016, March) STOP-Bang questionnaire a practical approach to screen for obstructive sleep apnea. Chest 2016; 149(3):631-638. (Level 5 evidence)

Chung, F., Yand, Y. and Liao, P (2013, December) Predictive performance of the STOP_Bang score for identifying obstructive sleep apnea in obese patients. Obesity Surgery. 23(12):2050-7. Abstract retrieved December 6, 2016 from PubMed database.

Clavellina-Gaytán, D. , Velázquez-Fernández, D., Del-Villar, E., Domínguez-Cherit, G., Sánchez, H., Mosti, M., et. al., (2015, March) Evaluation of spirometric testing as a routine preoperative assessment in patients undergoing bariatric surgery. Obesity Surgery. 25(3):530-6. Abstract retrieved December 6, 2016 from PubMed database.

Courcoulas, A., Christian, N., Belle, S., Berk, P., Flum, D., Garcia, L., et al. (2013). Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA, 310 (22), 2416-2425. (Level 3 evidence)

Degani-Costa, L., Faresin, S., and Falso, L. (2014, November) Preoperative evaluation of the patient with pulmonary disease. Revista Brasileira de Anestesiologia. 2014; 64(1)22-24. (Level 1 evidence)

Farina, A., Crimi, E., Accogli, S., Camerini, G., and Adami, G. (2012) Preoperative assessment of respiratory function in severely obese patients undergoing biliopancreatic diversion. European Surgical Research; 48:106-110. (Level 3 evidence)

Flum, D., Belle, S., King, W., Wahed, A., Berk, P. Chanpman, W., et. al. (2009, July) Perioperative safety in the longitudinal assessment of bariatric surgery (LABS) The New England Journal of Medicine. Vol. 361, No. 5, 445-454. (Level 1 evidence)

Gerber, P., Anderin, C. and Thorell, A. (2014) Weight loss prior to bariatric surgery: an updated review of the literature. Scandinavian Journal of Surgery 104:33-39. (Level 5 evidence)

Greenberg, I., Sogg, S., and Perna, F. (2011). Behavioral and psychological care in weight loss surgery: Best practice update. Obesity Journal, (17: 95), 880 - 884. (Level 3 evidence)

Heinberg, L. (2013, February). The role of psychological testing for bariatric/metabolic surgery candidates. Retrieved January 22, 2014 from http://bariatrictimes.com (Level 5 evidence).

Huisstede, A., Biter, L., Luitwieler, R., Cabezas, C., Mannaerts, G., Birnie, E, et. al. (2013, October) Pulmonary function testing and complications of laparoscopic bariatric surgery. Obesity Surgery; 23(10):1596-603. Abstract retrieved December 6, 2016 from PubMed database.

Kalarchian, M., Marcus, M., Courcoulas, A., Cheng, Y., & Levine, M. (2013). Preoperative lifestyle intervention in bariatric surgery: Initial results from a randomized controlled trial. Obesity, 21 (2), 254-260. (Level 1 evidence)

Livhits, M., Mercado, C., Yermilov, I., Parikh, J., Dutson, E., Mehran, A., et al. (2009). Does weight loss immediately before bariatric surgery improve outcomes: a systematic review. Surgery for Obesity and Related Diseases, 5 (09), 713-721. (Level 1 evidence)

Marcus, M., Kalarchian, M., Courcoulas, A. (2009). Psychiatric evaluation and follow-up of bariatric surgery patients. American Journal of Psychiatry, 166 (3), 285 - 291. (Level 3 evidence)

Michalsky, M., Kramer, R., Fullmer, M., Polfuss, M., Porter, R., Ward-Begnoche, W. et al. (2011). Developing criteria for pediatric/adolescent bariatric surgery programs. Pediatrics, 128 (2), S65 - S70.

National Institute for Health and Clinical Excellence. (2012, November).Clinical guidance: Obesity: identification, assessment and management. Retrieved October 20, 2015 from http://guidance.nice.org.uk.

National Institute of Health (2013) Systematic evidence review from the obesity expert panel, 2013. Retrieved January 30, 2017 from: http://www.nhlbi.gov/guidelines

Nguyen, N., Blackstone, R., Morton, J. Ponce, J. Rosenthal, R (Eds.). (2015) The ASMBS Textbook of Bariatric Surgery, Chapter 6 Indications and Contraindications for Bariatric Surgery (Volume 1, pp. 73-75.) New York: Springer Science+Business Media.

Pataky, Z., Carrad, I., & Golay, A. (2011). Psychological factors and weight loss in bariatric surgery. Current Opinion in Gastroenterology, 2011 (27), 167-173. (Level 5 evidence)

Pouwels, S., Said, M., and Celik, A. (2016, January) The necessity of preoperative pulmonary function screening in patients scheduled for bariatric surgery. Obesity & Weight Loss Therapy. Vol. 6:Issue 1. (Level 5 evidence)

Schroeder, R., Garrison, J. and Johnson, M. (2011, October) Treatment of adult obesity with bariatric surgery. American Family Physician. Vol. 84, No. 7 805-814. (Level 5 evidence)

Sjoholm, K., Anveden, A., Peltonen, M., Jacobson, P., Romeo, S., Svensson, P., et al. (2013). Evaluation of the current eligibility criteria for bariatric surgery. Diabetes Care, 36 (5), 1335 - 1340. (Level 2 evidence)

Snyder,A. (2009, Fall) The Ochsner Journal (Volume 9, Number 3, pp 144-149) Psychological Assessment of the Patient Undergoing Bariatric Surgery. New Orleans, LA: Ochsner Clinic Foundation.

Tao, W., Plecka-Östlund, M., Lu, Y., Mattsson,  F., and Lagergren, J. (2015, March-April) Causes and risk factors for mortality within 1 year after obesity surgery in a population-based cohort study. Surgery Obesity and Related Disorders; 11(2):399-405. Abstract retrieved December 6, 2016 from PubMed database.

Technology Evaluation Center. (2012, October). Bariatric surgery in patients with diabetes and BMI less than 35 kg/m2 with weight. (Vol. 27, No. 2). Chicago: BlueCross BlueShield Association. (33 articles and/or guidelines reviewed)

Technology Evaluation Center. (2012, October). Laparoscopic adjustable gastric banding in patients with BMI less than 35 kg/m2 with weight related comorbidity. (Vol. 27, No. 5). Chicago: BlueCross BlueShield Association. (19 articles and/or guidelines reviewed)

Trastulli, S., Desiderio, J., Guarino,S., Cirocchi, R., Scalercio, V., M.D.a, Noya, G., et. al., (January 2013) Laparoscopic sleeve gastrectomy compared with other bariatric surgical procedures: a systematic review of randomized trials. Surgery for Obesity and Related Diseases. 9 (2013) 816–830. (Level 1 evidence)

Tsai, A. and Schumann, R. (2016, February) Morbid obesity and perioperative complications. Current Opinion -  Anesthesiology. Vol 29, No. 1 103-8. (Level 5 evidence)

U. S. Food and Drug Administration. (2001, June) Center for Devices and Radiologic Health. Pre-market approval decision P000008 (Lap-Band®) Retrieved October 21, 2015 from: http://www.fda.gov.

U. S. Food and Drug Administration. (2007, September) Center for Devices and Radiologic Health. Pre-market approval decision P0700009. (Realize™) Retrieved October 21, 2015 from: http://www.fda.gov.

United States Preventive Services Task Force (USPSTF). (2012). Screening for and management of obesity in adults: USPSTF task force recommendation statement. Annals of Internal Medicine, 157 (5), 1-7.

Vilallonga, R., Fort, J., Caubet, E., Gonzalez, O., Balibrea, J., Ciudin, A., et. al. (August, 2015) Robotically assisted single anastomosis duodenoileal bypass after previous sleeve gastrectomy implementing high valuable technology for complex procedures. Journal of Obesity. Article ID 586419. (Level 5 evidence)

Winifred S. Hayes, Inc. Medical Technology Directory. (2012, October: last update search September 2015). Laparoscopic sleeve gastrectomy for super obesity in adults. Retrieved October 20, 2015 from www.Hayesinc.com (56 articles and/or guidelines reviewed)

Yen, Y., Huang, C., and Tai, C. (2014, September) Psychiatric aspects of bariatric surgery. Current Opinion Psychiatry. Vol. 27, No. 5, 374- 379. (Level 5 evidence)

ORIGINAL EFFECTIVE DATE:  12/10/1980

MOST RECENT REVIEW DATE:  6/21/2017

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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