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:
Gastric restrictive surgical procedures create a small gastric pouch, resulting in weight loss from early satiety and decreased dietary intake. The decreased capacity of the stomach reduces the volume of food an individual consumes before feeling full
Malabsorptive surgical procedures bypass a section of the small intestines. Weight loss results from intestinal malabsorption
Combination surgical procedures decrease the stomach capacity and bypassing part of the digestive tract, these techniques also result in metabolic changes due to gastrointestinal rearrangement.
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
Bariatric surgery, using a laparoscopic or open procedure, for the treatment of obesity is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.) (See also, brief description of various bariatric procedures above)
Bariatric surgery for the treatment of obesity using the following techniques is considered investigational:
Laparoscopic greater curve plication (LGCP) (i.e., total vertical gastric plication, gastric imbrication, gastric pleat)
Single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S; or two stage bariatric procedures)
Bariatric surgery for all other indications including but not limited to gastroesophageal reflux alone, glycemic control alone, lipid lowering alone or cardiovascular risk reduction alone independent of BMI criteria is considered investigational.
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
Bariatric surgery is considered medically appropriate if ANY ONE of the following criteria are met:
A revision, alteration or reversal of a previous bariatric procedure with ANY ONE of the following:
Physician documented medical complication
Physician documented surgical complication
An initial bariatric surgical procedure requested and ALL of the following:
Individual is 18 years of age or older
The Bariatric Surgery Precertification Request Form completed and submitted with the request for authorization
Diagnosis of morbid obesity classified as ANY ONE of the following:
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 with ANY ONE of the following obesity-related comorbidities:
Coronary artery disease
Type 2 diabetes mellitus
Obstructive sleep apnea
Hypertension (BP greater than 140 mmHg systolic and/or 90 mmHg diastolic)
Absence of ALL of the following excessive risk co-morbidities:
Contraindications to general anesthesia
Irreversible cardiopulmonary disorders (e.g. right heart failure, severe pulmonary arterial hypertension, advanced cardiomyopathy)
End-organ failure (e.g. end stage renal disease, candidate for transplant)
Metastatic or inoperable malignancy
Attending physician is someone other than the operating surgeon and his/her associates
Attending physician documents adherence to a non-surgical weight loss program (e.g. dietary management, behavior modification, and/or exercise) with ALL of the following:
Most recent attempt was within 2 years of request for surgery
Participation was for a minimum of 6 months.
Failure to achieve and/or maintain adequate weight loss (i.e. 10% or greater) by conservative means
Comprehensive psychosocial - behavioral evaluation with ALL of the following:
Submitted by a Psychiatrist or Psychologist
Clinical interview completed
At least one psychological test and/or assessment tool administered and evaluated (Possible choices: Minnesota Multiphasic Personality Inventory®-2, MMPI®-2-Restructured Form, or Millon® Behavioral Medicine Diagnostic with bariatric norms)
Absence of conclusion that individual is unable or unwilling to comply with requisite dietary and behavioral modifications.
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
This medical policy does not apply to CoverKids.
The cost of bariatric surgery for the treatment of morbid obesity may or may not be covered by insurance.
In 2016 the Center for Disease Control (CD) classified adult body mass index (BMI) for obesity as:
Class 1 obesity is BMI 30 to 34.9
Class 2 obesity is BMI 35 to 39.9
Class 3 obesity is BMI greater than or equal to 40
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.
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ORIGINAL EFFECTIVE DATE: 12/10/1980
MOST RECENT REVIEW DATE: 12/20/2017
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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