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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 will be used to determine your coverage.

Administrative process

Prior authorization is required for weight loss surgery re-operations.

Re-operations after an initial weight loss surgery generally fall into three categories:

  1. Surgical reversals (i.e., take downs) of the original procedure;
  2. Revisions; and
  3. Conversions

Please see the Definitions section for descriptions of these three types of re-operations.

Coverage criteria may vary:

  1. between the three types of re-operations AND
  2. between LAGB (laparoscopic assisted gastric band) surgery OR any of the other types of bariatric surgery. 

Please see Indications that are Covered sections below for details of coverage. Re-operations are covered when the member has been evaluated and treated by an in-network designated weight loss surgical physician and the criteria are met as specified below. 

Indications that are covered

  1. Re-Operation after failure of Laparoscopic Adjustable Gastric Banding (LAGB)
    1. Revisions or Reversals of LAGB are covered to:
      1. treat significant medical/surgical complications related to the surgery
      2. correct medical/surgical complications or malfunction of an implanted device (e.g. .laparoscopic gastric banding - 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.  Conversion after failure of LAGB is covered if ALL of the following criteria are met.
      1. Revisions to the LAGB have failed AND
        1. At least 2 years have elapsed since the previous bariatric procedure AND
        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 AND
        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.
  2. 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 (Takedown) Surgery
      1. Takedown surgery is only covered for a medical/surgical complication of surgery.
      2. Takedown surgery is not covered in the absence of a medical/surgical complication.
    2. Revisions of weight loss surgeries (other than the LAGB)
      1.  Revisions are covered to treat significant medical/surgical complications related to the surgery.
      2. The following endoluminal revision procedures are considered experimental / investigational and are not covered:
        1. Stomaphyx
        2. ROSE procedure – restorative obesity surgery – endoluminal
    3. Conversions of weight loss surgeries (other than LAGB):
      Conversions from one bariatric (weight loss) procedure (that was not a LAGB) to another is covered if:
      1. One of the following complications is present:
        1. One of the following complications is present:
        2. Stoma dilation or stenosis
        3. Stoma ulcer
        4. Severe gastroesophogeal reflux
        5. Mechanical obstruction
        6. Malnutrition
      2. Failure of the original surgery to produce weight loss without complications listed above, when all of the following criteria are met
        1. At least 2 years have elapsed since the previous bariatric procedure AND
        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 AND
        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

Weight loss surgery operations that do not meet the criteria above. 

Procedures considered investigational or experimental and requiring further study to demonstrate safety and efficacy of the procedure. These procedures include but are not limited to:

  1. The laparoscopic loop or "Mini-Gastric Bypass" is considered investigational.
  2. Balloon procedures are considered investigational.
  3. Implantable gastric stimulator is considered investigational.
  4. Endoluminal procedures, including but not limited to:
    1. Stomaphyx
    2. ROSE procedure – restorative obesity surgery - endoluminal
    3. Transoral gastroplasty

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

Surgical reversal (Takedown) Procedures: 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)

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:

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

43842

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


43659

Unlisted laparoscopy procedure, stomach

43843

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

43999

Unlisted procedure, stomach

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.