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HealthPartners

Coverage criteria policies

Weight loss surgery

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior Notification is required for weight loss (bariatric) surgery performed by a designated physician in one of the Preferred Choice Weight Loss Surgery Programs. See related content section at the right for a list of preferred weight loss surgery programs.

Prior Authorization is required for weight loss (bariatric) surgery performed by any physician other than a designated physician in one of the Preferred Choice Weight Loss Surgery Programs. See related content section at the right for a list of preferred weight loss surgery programs.

This policy applies only to initial weight loss (bariatric) surgery procedures. Refer to the Weight Loss Surgery Re-operations policy for information and coverage criteria for revisions or additional weight loss surgeries.

Coverage

We encourage members to check with Member Services regarding their health plan benefits for weight loss surgery as well as any provider network limitations that may impact coverage. Member Services can be reached at 952-883-5000 or 1-800-883-2177 (outside the metro area). All members must meet criteria for coverage regardless of where the service is provided.

Indications that are covered

Weight loss surgery may be eligible for coverage in a member 18 years of age and older when ALL of the following criteria are met:

  1. A member must have a documented Body Mass Index (BMI) equal to or greater than 40 or a documented BMI greater than 35 with associated health conditions that do not respond to medical management. Associated health conditions for the purpose of this topic are defined as:
    • High blood pressure that is consistently greater than 140/90 on multiple, separate dates despite treatment that has followed standard treatment recommendations of multiple medications, alone and/or in combination, for amounts of time that are generally considered adequate to see treatment success with demonstrated patient compliance to the prescribed treatments; OR
    • Dyslipidemia with cholesterol LDL consistently greater than or equal to 130 mg/dl separate dates despite treatment that has followed standard treatment recommendations of multiple medications, alone and/or in combination, for amounts of time that are generally considered adequate to see treatment success with demonstrated patient compliance to the prescribed treatments; OR
    • Clinically significant obstructive sleep apnea (OSA) that has not responded to medical management, confirmed on polysomnography with an apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) equal to or > 30;, OR
    • Diabetes with glycosylated hemoglobin level (HbA1c) that is greater than or equal to 7 on multiple, separate dates, treatment that has followed standard treatment recommendations of multiple medications, alone and/or in combination, for amounts of time that are generally considered adequate to see treatment success with demonstrated patient compliance to the prescribed treatments; OR
    • Pseudotumor cerebri (a condition in which the pressure around the brain increases, causing headaches and vision problems) not responding to optimal medical management.

AND

  1. All candidates for weight loss surgery must have completed all of the following:
    1. Documentation of an evaluation by a mental health professional which addresses the following:
      • The need for any active therapeutic interventions for mental health issues and a plan on how these issues will be addressed;
      • The ability of the member to participate in:
        1. Close nutritional monitoring during rapid weight loss, and
        2. Long term lifestyle changes;
      • Certification that the member understands the full impact of surgery and post-op compliance.
    2. At least one session of nutritional counseling with a clinical dietician and documentation of education as well as certification of member’s commitment to post-op compliance program.
    3. Documentation of participation in an exercise program deemed appropriate for the member by the care team and documentation of member’s commitment to continue post-operatively.
    4. Documentation by the weight loss surgery surgical team that any correctable endocrine disorders and/or other medical conditions have been ruled out.
    5. Appropriate documentation and assertion by the operating surgeon that the member understands the surgical procedure chosen, the side effects, the risks, and the weight loss expectations/results.
    6. Documentation of at least 5 completed sessions of the HealthPartners’ Weight loss surgery program phone course. For further information about this phone-based curriculum, please see the related content at the right. You will be referred into this program by your surgical team. NOTE: Members may qualify for weight loss surgery without active participation in HealthPartners’ Weight loss surgery phone course if they have a documented qualifying BMI AND an urgent health care condition (e.g., transplantation, significant diabetic complications, malignant hypertension, Pickwickian syndrome).
    7. Documentation which certifies the member’s commitment to participation in close nutritional monitoring during rapid weight loss, long-term lifestyle changes, diet prescription, and medical surveillance after surgical therapy.

Weight Loss Surgery Procedures that are eligible for coverage when the above criteria are met. See Definitions section below for an explanation of these procedures:

  1. Roux-en-Y Gastric Bypass (RYGBP)
  2. Biliopancreatic diversion with duodenal switch (BPD/DS)
  3. Sleeve gastrectomy
  4. Vertical gastric banding (VGB)
  5. FDA-approved adjustable gastric banding. Examples of FDA approved devices used for adjustable gastric banding include but are not limited to: LAP-BAND, Realize™ Personalized Banding Solution, Swedish adjustable gastric banding (SAGB), etc.

Weight Loss Surgery Procedures that are not eligible for coverage despite the above criteria being met:

The following weight loss procedures are considered investigational. There is insufficient reliable evidence in the form of high-quality, peer-reviewed medical literature to establish the safety and efficacy of these treatments or their effect on health care outcomes. These procedures include but are not limited to:

  1. The laparoscopic loop or “Mini-Gastric Bypass”
  2. Intragastric balloon procedures
  3. Implantable gastric stimulator
  4. Endoluminal procedures, including but not limited to:
    1. Stomaphyx
    2. ROSE procedure- restorative obesity surgery-endoluminal
    3. Transoral gastroplasty
  5. Vagal Blocking for Obesity Control (VBLOC)

Indications that are not covered

  1. Any weight loss/bariatric surgery procedure to treat co-morbidities caused by or exacerbated by obesity unless in accordance with the criteria listed above is considered investigational. There is insufficient published evidence to support bariatric surgery as a definitive treatment for obesity associated diseases. These types of procedures will frequently improve symptoms of diabetes, gastroesophageal reflux disease (GERD), osteoarthritis, obstructive sleep apnea (OSA), etc. However, the primary purpose of bariatric surgery is to achieve weight loss.
  2. Weight loss surgery in a member with a BMI less than 35 is considered cosmetic.

Definitions

Body Mass Index (BMI) is measure of body fat based on height and weight that applies to both adult men and women. Please see related content at right for link to calculate your BMI.

Obesity is defined as a Body Mass Index (BMI) greater than or equal to 30. Obesity is divided into three classifications according to the BMI:

    • Class I - BMI 30.0 to 34.9.
    • Class II - BMI 35.0 to 39.9.
    • Class III - BMI 40 and above.

Obesity is a chronic condition that develops from an interaction of genetics and the environment. Because of these multiple factors, weight loss surgery is not considered to be the first or only treatment for obesity. Treatment requires comprehensive medical and behavioral management. Weight loss and weight control programs use multiple interventions and strategies, including individualized dietary therapy, physical activity, life-style/behavior therapy and surgery. Weight loss surgery is reserved for a limited number of adults whose obesity is:

    • Class II and efforts at combined therapies of diet, exercise, and behavioral management have failed and other medical condition(s) existing simultaneously and usually independently of the severe obesity (co-morbidities).
    • Class III and efforts at combined therapies of diet, exercise, and behavioral management have failed and are at high risk for obesity-associated co-morbidity or death (mortality).

Weight loss surgery is intended to provide weight loss sufficient to reduce mortality risk and improve medical conditions when less invasive methods of weight loss have failed.

Weight loss surgery is not an alternative to a diet and exercise management program. An integrated program such as HealthPartners’ Weight loss surgery phone course must be in place to provide guidance on diet, physical activity, and behavioral and social support both prior to and after the surgery. Weight loss surgery is a weight loss intervention option for well-informed, motivated individuals with an acceptable operative risk.

Descriptions of bariatric surgery procedures:

Roux-en-Y Gastric Bypass (RYGBP) 43644, 43846

The RYGBP works via restriction and malabsorption. . Reduction of the stomach to a small gastric pouch (30 cc) results in feelings of satiety following even small meals. This small pouch is connected to a segment of the jejunum, bypassing the duodenum and very proximal small intestine, thereby reducing absorption. RYGBP procedures can be open or laparoscopic.

Biliopancreatic Diversion with Duodenal Switch (BPD/DS) 43845

BPD works via restriction and malabsorption. The stomach is partially resected, but the remaining capacity is generous compared to that achieved with RYGBP. As such, members eat relatively normal-sized meals and do not need to restrict intake radically, since the most proximal areas of the small intestine (i.e., the duodenum and jejunum) are bypassed, and substantial malabsorption occurs. The partial BPD with duodenal switch is a variant of the BPD procedure. It involves resection of the greater curvature of the stomach, preservation of the pyloric sphincter, and transection of the duodenum above the ampulla of Vater with a duodeno-ileal anastamosis and a lower ileo-ileal anastamosis. BPD/DS procedures can be open or laparoscopic.

Sleeve Gastrectomy 43775

Sleeve gastrectomy is a 70%-80% greater curvature gastrectomy (sleeve resection of the stomach) with continuity of the gastric lesser curve being maintained while simultaneously reducing stomach volume. It may be the first step in a two-stage procedure when performing RYGBP. Sleeve gastrectomy procedures can be open or laparoscopic.

Vertical Gastric Banding (VGB) 43842

VBG works via restriction only. . The upper part of the stomach is stapled, creating a narrow gastric inlet or pouch that remains connected with the remainder of the stomach. In addition, a non-adjustable band is placed around this new inlet in an attempt to prevent future enlargement of the stoma (opening). As a result, members experience a sense of fullness after eating small meals. Weight loss from this procedure results entirely from eating less.

Adjustable Gastric Banding (AGB) 43770-43774; 43886-43888; S2083

AGB works via restriction only. A band creating a gastric pouch with a capacity of approximately 15 to 30 cc’s encircles the uppermost portion of the stomach. The band is an inflatable doughnut-shaped balloon, the diameter of which can be adjusted in the clinic by adding or removing saline via a port that is positioned beneath the skin. The bands are adjustable, allowing the size of the gastric outlet to be modified as needed, depending on the rate of a member’s weight loss. ABG procedures are laparoscopic only.

Laparoscopic loop or Mini-Gastric Bypass

Mini-Gastric Bypass works via restriction and malabsorption. The stomach is divided and a small tube of stomach is created which becomes the pouch. Then the surgeon brings up a loop of bowel and joins it to the lower part of the stomach pouch. The food passes from the stomach pouch into the small bowel where it meets the digestive juices which have moved downwards from the main part of the stomach. Thus, approximately 6 feet of small bowel has been bypassed before absorption of food (and calories) can take place, producing weight loss via fewer calories being absorbed.

Intragastric balloon systems are acid –resistant balloons that are inserted into the stomach via endoscope and then expanded with saline or air. The balloons occupy space and promote weight loss by creating a feeling of fullness which can lead to decreased food consumption. The device is in place for approximately 6 months before being retrieved.

Implantable gastric stimulators for treatment of obesity are intended to induce early satiety and thus limit intake through electrical stimulation of the gastric wall.

Transoral gastroplasty (TG) is a minimally invasive, incision-less, reversible weight-loss procedure in which the stomach size is restricted with staples or sutures by using endoscopic surgical tools guided through the mouth and esophagus into the stomach. Two examples of this procedure that are proposed for revisions of standard weight loss surgery are Stomaphyx and the ROSE procedure (restorative obesity surgery – endoluminal).

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

CPT Codes for procedures that are covered when they meet the above criteria:

Codes

Description

43644

Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)

43645

Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption

43770

Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components)

43771

Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only

43772

Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only

43773

Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only

43774

Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components

43775

Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy

43842

Gastric restrictive procedure, without gastric bypass, for morbid obesity;

vertical banded gastroplasty

43843

Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty

43845

Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch)

43846

Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy

43847

Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption

43848

Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)

43886

Gastric restrictive procedure, open; revision of subcutaneous port component only

43887

Gastric restrictive procedure, open; removal of subcutaneous port component only

43888

Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only

CPT Codes for procedures that may be covered when they meet the above criteria:

Codes

Description

43659

Unlisted laparoscopy procedure, stomach

Experimental/Investigational procedures

Codes

Description

43999

Unlisted procedure, stomach

64590

When used for weigh loss - Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling (Note – this code may be covered for indications other than for weight loss).

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Adams, T., Davidson, L., Litwin, S., Kolotkin, R., LaMonte, M. Pendleton, R. …Hunt, S. (2012). Health Benefits of Gastric Bypass Surgery After 6 Years. Journal of the American Medical Association (JAMA), 308(11):1122-1131.
  2. American Academy of Sleep Medicine-Adult Obstructive Sleep Apnea Task Force (2009). Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults, Journal of Clinical Sleep Medicine, 5(3): 263-276.
  3. American Academy of Sleep Medicine Task Force (1999). Sleep –Related Breathing Disorders in Adults: Recommendations for Syndrome Definition and Measurement Techniques in Clinical Research, Sleep, 22(5):667-689.
  4. American Diabetes Association (2016). Standards of Medical Care in Diabetes- 2016, Diabetes Care-The Journal of Clinical and Applied Research and Education, 39(Suppl. 1): S1-S106.
  5. American Heart Association (2015). Treating Obesity as a Disease. Retrieved from http://www.heart.org, Sept, 2016.
  6. Calhoun, D., Jones, D., Textor, S., Goff, D., Murphy, T., Toto, R.,... Carey, R. (2008). Resistant Hypertension: Diagnosis, Evaluation, and Treatment. A Scientific Statement From the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Circulation, 108. Retrieved from http://circ.ahajournals.org, March 2016.
  7. Courcoulas, A., Belle, S., Neiberg, R., Pierson, S., Eagleton, J., Kalachian, M., …Jakicic, J. (2015). Three-Year Outcomes of Bariatric Surgery vs Lifestyle Intervention for Type 2 Diabetes Mellitus Treatment- A Randomized Clinical Trial. JAMA Surgery 2015.1534. Retrieved from http://archsurg.jamanetwork.com, Oct, 2015.
  8. ECRI Institute. (2016). Intragastric Balloons for Treating Obesity. Plymouth Meeting, PA: ECRI Institute.
  9. ECRI Institute. (2015). Metabolic Surgery for Treating Type 2 Diabetes Mellitus Regardless of Patient BMI. Plymouth Meeting, PA: ECRI Institute.
  10. ECRI Institute. (2016). Rechargeable Vagal Blocking System (Maestro) for Treating Obesity. Plymouth Meeting, PA: ECRI Institute.
  11. Fitch, A., Everling L, Fox C, Goldberg J, Heim C, Johnson K, Kaufman T, Kennedy E, Kestenbaun C, Lano
  12. M, Leslie D, Newell T, O’Connor P, Slusarek B, Spaniol A, Stovitz S, Webb B. Institute for Clinical Systems Improvement. Prevention and Management of Obesity for Adults. Updated May 2013. Retrieved from http://www. icsi.org, Sept, 2016.
  13. Hayes, Inc. Directory. Intragastric Balloons for the Treatment of Obesity. Lansdale, PA. Hayes, Inc. March, 2016.
  14. Hayes, Inc. Directory. Laparoscopic Bariatric Surgery: Roux-en-Y Gastric Bypass, Vertical Banded Gastroplasty and Adjustable Gastric Banding. Lansdale, PA: Hayes, Inc. June, 2007. Archived, 2012.
  15. Hayes, Inc. Directory. Roux-en-Y Gastric Bypass for Diabetes in Obese or Severely Obese Patients. Lansdale, PA: Hayes, Inc. Aug, 2014. Annual Review, Aug, 2016.
  16. Hayes, Inc. Directory. Roux-en-Y Gastric Bypass for Gastroesophageal Reflux Diesase in Obese or Severely Obese Patients. Lansdale, PA: Hayes, Inc. July, 2013. Annual Review, May, 2016.
  17. Hayes, Inc. Health Technology Brief. Maestro Rechargeable System (EnteroMedics Inc.) for Vagal Blocking for Obesity Control. Lansdale, PA: Hayes, Inc. Feb, 2016.
  18. Hayes, Inc. Subscriber Article. ReShape Integrated Dual Balloon System. Lansdale, PA: Hayes, Inc. Feb, 2016.
  19. Hsu, C., Almulaifi, A., Chen, J., Ser, K., Chen, S. Hsu, K. …Lee, W. (2015). Effect of Bariatric Surgery vs Medical Treatment on Type 2 Diabetes in Patients With Body Mass Index Lower Than 35- Five-Year Outcomes. JAMA Surgery 2015.2602. Retrieved from http://archsurg.jamanetwork.com, Oct, 2015.
  20. Lee, A. & Wall, M. Idiopathic intracranial hypertension (pseudotumor cerebri): Prognosis and Treatment. In: UpToDate, Brazis, P. (Ed) & Wilterdink, J. (Ed), UpToDate, Waltham, MA. (Accessed on Sept 27, 2016).
  21. Lim, R. Bariatric operations for management of obesity: Indications and pre-operative preparation. In: UpToDate, Jones, D. (Ed) & Chen, W. (Ed), UpToDate, Waltham, MA. (Accessed on Sept 27, 2016).
  22. McCulloch, D. Management of persistent hyperglycemia in type 2 diabetes mellitus. In: UpToDate, Nathan, D. (Ed) & Mulder, J. (Ed). UpToDate, Waltham, MA. (Accessed Sept 26, 2016).
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