UM Guidelines
Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy - Upcoming Changes

Inpatient and Surgical Care (ISC)

To be effective November 2, 2021*

BCBST will be archiving the current modification for Subsequent surgical procedure criteria and the Correction (revision or reversal) of the surgery criteria listed within the guidelines below.

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).
      • ...
    • 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
      • 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: Begin as 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. April - June 2021.

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