|Gastric Restrictive Procedure with Gastric Bypass|
Inpatient and Surgical Care (ISC)
|BCBST last reviewed August 31, 2021*|
Added to Clinical Indications: Procedure may be indicated for 1 or more of the following:
- Initial procedure in indicated for...
- Severity of obesity judged appropriate for procedure as indicated by...
- Patient is candidate for bariatric surgery as indicated by...
Patient has demonstrated reliable participation in preoperative multidisciplinary behavior modification program (eg, preparation for the postoperative diet and exercise regimens).
- Patient is receiving treatment in multidisciplinary program experienced in obesity surgery that can provide ALL of the following:
Surgeons experienced with procedure
- Preoperative medical consultation [and approval from primary care physician, nurse practitioner or physician assistant]*
- [Subsequent surgical procedure is indicated is indicated with ALL the following:
- Patient is requesting conversion from the initial surgical procedure to a different type of gastric restrictive procedure
- Requested procedure is not an investigational procedure
- Request is two (2) years or more since the initial surgery
- Weight loss is less than 50% of initial procedure pre-operative excess body weight
- Weight remains at least 30% over ideal body weight (using standard tables for adult ranges from the National Heart Lung and Blood Institute: http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm
- Current substance abuse is not identified
- Patient is receiving treatment in a multidisciplinary program experienced in metabolic surgery that can provide ALL the following:
- Preoperative medical consultation and approval from primary care physician, nurse practitioner or physician assistant
- Preoperative psychiatric consultation and conclusion that the individual is able and willing to comply with requisite dietary and behavioral modifications following surgery
- Nutritional counseling
- Exercise counseling
- Patient support programs]*
- [A correction (revision) or reversal of the initial surgery is indicated by ALL of the following:
- Patient requires 1 or more of the following:
- Correction (revision) of the previous surgical procedure
- Reversal of the previous surgical procedure
- The revision or correction is not an investigational procedure
- Physician documented complication related to the original surgery (e.g., fistula, obstruction, erosion, disruption/leakage of suture/staple line, band herniation, or pouch enlargement not due to overeating)]*
American Association Of Clinical Endocrinologist, American College Of Endocrinology, The Obesity Society, American Society For Metabolic & Bariatric Surgery, Obesity Medicine Association, American Society Of Anesthesiologist. (2019, December). 2019 Guidelines. AACE/TOS/ASMBS/OMA/ASA clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures. Retrieved March 17, 2020 from https://journals.aace.com/doi/pdf/10.4158/GL-2019-0406.
BlueCross BlueShield of Tennessee network physicians. Apil - June 2021.
Download Acrobat Reader