Skip to main content
HealthPartners

Coverage criteria policies

Weight Loss Surgery-Re-operations

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 authorization is required for weight loss (bariatric) surgery re-operations.

Coverage

We encourage members to check with Member Services regarding their health plan benefit for weight loss surgery re-operations as well as any provider network limitations that may impact coverage.

Re-operations after an initial weight loss surgery generally fall into three categories. Please see the Definitions section below for a description of the following procedures:

  • Surgical reversals (I.e. take-downs) of the original procedure;
  • Revisions; and
  • Conversions

Note that coverage criteria may vary between the three types of re-operations as well as between re-operations following laparoscopic adjustable gastric banding (LAGB) versus other types of weight loss surgery.

Indications that are covered

Re-operations after failure of Laparoscopic Adjustable Gastric Banding (LAGB):
  1. Revisions or Reversals of LAGB may be eligible for coverage to:
    1. Treat significant medical/surgical complications related to the surgery
    2. Correct medical/surgical complications or malfunction of an implanted device (such as a LAGB) including:
      1. Slippage of the band
      2. Erosion in the area of the band
      3. Port related complications
      4. Concentric dilatation
      5. Esophageal dilatation
  2. Conversions after failure of LAGB may be eligible for coverage when revisions of the LAGB have failed and ALL of the following criteria are met:
    1. At least 2 years have elapsed since the previous bariatric procedure
    2. The member is currently greater than 30% above ideal body weight
    3. Compliance with the previously prescribed postoperative dietary and exercise program is documented by the member’s primary care physician or surgeon every 3 months for one year before the surgery
    4. The member has completed at least 5 sessions with HealthPartners’ weight loss surgery program phone course. For further information about this phone-based curriculum, please see the Related Content at the right for the Weight loss surgery candidates’ pre- and post-operative phone-based curriculum Frequently Asked Questions. You will be referred into this program by your surgical team. The member must meet these program requirements prior to a second bariatric surgery even if they completed the course prior to their first bariatric surgery.

Re-operations after other weight loss surgeries including but not limited to:

  • Roux-en-Y Gastric Bypass (RYGBP)
  • Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
  • Sleeve Gastrectomy
  • Vertical Gastric Banding (VGB)
  1. Reversal (take-down) surgery
    1. Take-down surgery may be eligible for coverage only to treat a significant medical/surgical complication related to the initial surgery.
  2. Revision of weight loss surgeries (other than LAGB)
    1. Revision surgeries may be eligible for coverage only to treat significant medical/surgical complications related to the initial surgery.
  3. Conversions from one weight loss surgery (that was not a LAGB) to another may be eligible for coverage when:
    1. One of the following complications is present:
      1. Stoma dilation or stenosis
      2. Stoma ulcer
      3. Severe gastroesophageal reflux
      4. Mechanical obstruction
      5. Malnutrition

Or

    1. There is documented failure of the original surgery to produce weight loss without the complications listed above, when ALL of the following criteria are met:
      1. At least 2 years have elapsed since the previous bariatric procedure
      2. The member is currently greater than 30% above ideal body weight
      3. Compliance with the previously prescribed postoperative dietary and exercise program is documented by the member’s primary care physician or surgeon every 3 months for one year before the surgery
      4. The member has completed at least 5 sessions with HealthPartners’ weight loss surgery program phone course. For further information about this phone-based curriculum, please see the Related Content at the right for the Weight loss surgery candidates’ pre- and post-operative phone-based curriculum Frequently Asked Questions. You will be referred into this program by your surgical team. The member must meet these program requirements prior to a second bariatric surgery even if they completed the course prior to their first bariatric surgery.

Indications that are not covered

The following weight loss surgery procedures are not eligible for coverage despite the above criteria being met as they 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:

  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 (Restorative obesity surgery-endoluminal) procedure
    3. Transoral gastroplasty
  5. Vagal Blocking for Obesity (VBLOC)

Definitions

Weight Loss (Bariatric) re-operation: refers to subsequent surgery for morbid obesity on a member who had prior bariatric surgical procedures. Re-operations may include surgical reversals (i.e. take-downs) of the original procedure, revisions, and conversions.

Surgical reversal (Take-down): Surgery to reverse the anatomic changes from the initial procedure.

Revision surgery: Surgery to restore the effectiveness of the original bariatric procedure

Conversion surgery: Surgery to change from one type of bariatric procedure to a different procedure (e.g. conversion of a vertical banded gastroplasty to a Roux-en-Y procedure.

Laparoscopic loop or 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.

The services associated with these codes are eligible for coverage]:

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

43659

Unlisted laparoscopy procedure, stomach

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

The following codes are considered 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. Brethauer, S., M.D., Kothari, S., M.D., Sudan, R., M.D., Williams, B. M.D., English, W., M.D. Brengman, M., M.D….Morton, J., M.D. (2014). Systematic Review on Reoperative Surgery, Surgery for Obesity and Related Diseases. American Society of Metabolic and Bariatric Surgeons.
  2. ECRI Institute. (2014). Custom Rapid Response, Repeat Bariatric Surgery For Patients Who Have Not Reached Weight-Loss Goals After Previous Surgery. Plymouth Meeting, PA: ECRI Institute.
  3. ECRI Institute. (2016). Intragastric Balloons for Treating Obesity. Plymouth Meeting, PA: ECRI Institute
  4. ECRI Institute. (2016). Rechargeable Vagal Blocking System (Maestro) for Treating Obesity. Plymouth Meeting, PA: ECRI Institute.
  5. Hayes, Inc. Directory Report. Intragastric Balloons for the Treatment of Obesity. Lansdale, PA. Hayes, Inc. March, 2016.
  6. Hayes, Inc. Directory Report. Revisional Surgery for Treatment of Complications After Bariatric Surgery. Lansdale, PA: Hayes, Inc.; July, 2014. Annual review, July, 2016.
  7. Hayes, Inc. Health Technology Brief. Maestro Rechargeable System (EnteroMedics Inc.) for Vagal Blocking for Obesity Control. Lansdale, PA: Hayes, Inc. Feb, 2016.
  8. Hayes, Inc. Subscriber Article. ReShape Integrated Dual Balloon System. Lansdale, PA: Hayes, Inc. Feb, 2016.Kuzminov, A., Palmer, A., Wilkinson, S., Khatsiev, B. & Venn, A. (2016) Re-operations after Secondary Bariatric Surgery: a Systematic Review. Obesity Surgery 26:2237-2247.