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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.

Weight loss surgery is generally not covered for cosmetic reasons to improve the appearance of the member, but may be covered subject to the indications listed below.

We encourage members to check with Member Services regarding their health plan benefits for weight loss surgery. 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 is covered when the member has been evaluated and treated by an in-network designated weight loss surgical physician and all of the following are met:

  1.  A member must have a documented history of BMI equal to or greater than 40 or a documented history of a 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 (BP) of 140/90 or greater, or
    • Dyslipidemia with cholesterol LDL greater than or equal to 130 mg/dl, or
    • Self reported sleep apnea with use of CPAP or other related sleep apnea treatments, or
    • Diabetes with glycosylated hemoglobin level (HbA1c) that is greater than  or equal to 7,
    • Pseudotumor cerebri, and
    • These health conditions are not responding to optimal medical management.

      AND
  2. 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. Participation in an appropriate exercise program and documentation of member’s commitment to continue post-operatively.
    4. Evaluation by a surgical team in the HealthPartners Weight Loss Surgery network.  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. Documented qualifying BMI AND with at least 5 completed 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.  You will be referred into this program by your surgical team.

      AND
       
    7. The member is committed to participation in close nutritional monitoring during rapid weight loss, long-term lifestyle changes, diet prescription, and medical surveillance after surgical therapy.
  3. 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).
Weight Loss Surgery Procedures that are covered when the above criteria are met:
  1. Roux-en-Y Gastric Bypass (RYGBP)
  2. Biliopancreatic diversion with duodenal switch (BPD/DS)
  3. Vertical Gastric Banding (VGB)
  4. FDA-approved adjustable gastric banding technique:  Examples of FDA approved devises used for adjustable gastric banding include but are not limited to  LAP-BAND, Realize™ Personalized Banding Solution, Swedish adjustable gastric banding (SAGB), etc.
  5. Sleeve gastrectomy

Revisions or Additional Weight Loss Surgeries/Re-Operations - Please see related content at right for link to Weight Loss Surgery Re-Operations Policy.

Indications that are not covered

Conditions for which weight loss surgery is not covered:

  1. When evaluation documentation and BMI classifications as listed above are not met.
  2. For BMI less than 35.
  3. Children and adolescents less than 18 years of age.
  4. When performed by any provider other than an in-network designated weight loss surgery provider.

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 (64590)
  4. Endoluminal procedures, including but not limited to:
    1. Stomaphyx
    2. ROSE procedure – restorative obesity surgery - endoluminal
    3. Transoral gastroplasty

Associated surgeries that are not covered:

  1. Panniculectomy after bariatric surgery is generally considered cosmetic and is not covered.  Please see related content at right for link to Abdominoplasty/panniculectomy policy for details.

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 person who has a Body Mass Index (BMI) greater than or equal to 30. Obesity is divided into three classifications according to the persons 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 achieves weight loss by gastric 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 achieves weight loss by gastric 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.

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

AGB achieves weight loss by gastric 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.

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 achieves weight loss by gastric 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.

Transoral gastroplasty (TG) is a minimally invasive, incisionless, 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:

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:

43659

Unlisted laparoscopy procedure, stomach

Experimental/investigational procedures


43999

Unlisted procedure, stomach

64590When 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.

These coverage criteria are supported by an Institute of Clinical Systems Improvement (ICSI) technology assessment.

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.