UM Guidelines
Gastric Restrictive Procedure without Gastric Bypass by Laparoscopy

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 is 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).
      • ... 
      • [Individual is 18 years of age or older]*
      • ...
    • 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:
    • 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
      • Psychological 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)]*


Added to: Hospitalization - Goal Length of Stay
Goal Length Of Stay: Observation


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

BlueCross BlueShield of Tennessee network physicians. January - April 2021.

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