Bariatric Surgery

Policy Number: Original Effective Date: MM.06.003 09/11/2001 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 09/26/2014 Section: Surgery Place(s) of Service: Outpatient; Inpatient

I. Description Surgery for morbid , termed , falls into two general categories: 1) gastric- restrictive procedures that create a small gastric pouch, resulting in weight loss by producing early satiety and thus decreasing dietary intake; and 2) malabsorptive procedures, which produce weight loss due to malabsorption by altering the normal transit of ingested food through the . Some bariatric procedures may include both a restrictive and a malabsorptive component. HMSA is carefully monitoring the evolving literature and specialty society recommendations regarding the efficacy of lap band. Though we do not believe there is enough evidence at present to stop covering this procedure, HMSA believes providers should make it clear to members that current best practice distinctly favors gastric bypass and sleeve over placement of a lap band. Morbid obesity is defined as a body mass index (BMI) greater than 40 kg/m2 or a BMI greater than 35 kg/m2 with associated complications including, but not limited to, diabetes, hypertension, or obstructive sleep apnea. Morbid obesity results in a very high risk for weight-related complications, such as diabetes, hypertension, obstructive sleep apnea, and various types of cancers (for men: colon, , and prostate; for women: breast, uterus, and ovaries), and a shortened life span. A 1991 National Institutes of Health (NIH) Consensus Conference defined surgical candidates as those patients with a BMI of greater than 40 kg/m2, or greater than 35 kg/m2 in conjunction with severe comorbidities such as cardiopulmonary complications or severe diabetes. Resolution (cure) or improvement of type 2 diabetes mellitus after bariatric surgery and observations that glycemic control may improve immediately after surgery, before a significant amount of weight is lost, have promoted interest in a surgical approach to treatment of type 2 diabetes. The various surgical procedures have different effects, and gastrointestinal rearrangement seems to confer additional anti-diabetic benefits independent of weight loss and caloric restriction. The precise mechanisms are not clear, and multiple mechanisms may be involved. Gastrointestinal peptides, glucagon-like peptide-1 (1GLP-1), glucose -dependent insulinotropic peptide (GIP), and peptide YY (PYY) are secreted in response to contact with unabsorbed nutrients and by vagally Bariatric Surgery 2

mediated parasympathetic neural mechanisms. GLP-1 is secreted by the L cells of the distal ileum in response to ingested nutrients and acts on pancreatic islets to augment glucose-dependent insulin secretion. It also slows gastric emptying, which delays digestion, blunts postprandial glycemia, and acts on the central nervous system to induce satiety and decrease food intake. Other effects may improve insulin sensitivity. GIP acts on pancreatic beta cells to increase insulin secretion through the same mechanisms as GLP-1, although it is less potent. PYY is also secreted by the L cells of the distal intestine and increases satiety and delays gastric emptying.

II. Criteria/Guidelines HMSA strongly recommends that prior to considering bariatric surgery, patients be evaluated by a multi-disciplinary clinical team (e.g., endocrinologists, psychiatrists, surgeons, dieticians, nurse practitioners) at a Medicare defined Center of Excellence or at a program that offers comprehensive weight management services. The program should contain the following services and be offered at the same location as the proposed surgical procedure to insure continuity of care: Nutrition counseling Weight-loss program Exercise guidance and support Education about lifestyle changes Preparation and follow up for surgery Support groups for patients before and after surgery A. Surgery for morbid obesity is covered (subject to Limitations/Exclusions and Administrative Guidelines) for members when the following criteria are met: 1. The patient is morbidly obese, defined as either of the following: a. Persistent and uncontrollable weight gain that constitutes a present or potential threat to life; i. Weight that is at least 100 pounds over or twice the ideal weight as described in the Metropolitan Life tables; or ii. A BMI greater than 40 kg/m²; or b. BMI of between 35 and 40 kg/m² with one of the following high-risk comorbidities: i. Severe sleep apnea (defined as repeated hypoxia with oxygen saturation less than 80% on sleep study; or documented pulmonary hypertension on echocardiogram or right heart catheterization; or sleep apnea induced right heart failure requiring hospitalization). ii. Pickwickian syndrome iii. Obesity-related cardiomyopathy iv. Type II diabetes mellitus with evaluation and recommendation for surgery by a multi-disciplinary team with expertise in weight, metabolic, and diabetic management and which is part of a comprehensive weight management program associated with the facility where the surgery will be performed. c. BMI of between 30 and 34.9 kg/m2 with type II diabetes Type II diabetes mellitus with evaluation and recommendation for roux-en-Y by a multi-disciplinary team with expertise in weight, metabolic, and diabetic management and which is part of a comprehensive weight management Bariatric Surgery 3

program associated with the facility where the surgery will be performed. For this category of patient, only Roux-en-Y gastric bypass is covered as the evidence has shown compelling benefit specifically with this particular operation, and not the other alternatives. 2. The surgery is intended to achieve one of two results: a. Alteration of the mechanics of food absorption; or b. Alteration in the volume of food ingested. 3. There is documentation that the patient's efforts to lose weight have not been successful. B. Surgery for morbid obesity in adolescents is covered (subject to Limitations/Exclusions and Administrative Guidelines) when the member meets the same weight-based criteria used for adults but greater consideration will be given to psychosocial and informed consent issues. All devices must be used in accordance with FDA-approved indications. C. Revisions, replacements, and re-dos of bariatric procedures are covered (subject to Limitations/Exclusions and Administrative Guidelines) if the patient met policy criteria at the time of the initial procedure, and there is documentation of a medically significant complication or failure. D. Bariatric surgery is covered only if the patient meets the criteria outlined above and when: 1. The facility is located in the state of Hawaii, has a contract with HMSA to perform bariatric surgery and has a comprehensive weight management program; or 2. The facility is an approved Blues Distinction Center for bariatric surgery with an agreement for continuity of care in the state where the member primarily resides. III. Limitations/Exclusions A. Lap band procedures must be performed in the outpatient setting unless the physician is recommending the procedure be done in an inpatient setting. When requesting pre- certification, the physician should outline concerns about the member's comorbidities, complex problems, age considerations, etc. B. Polysomnography performed as part of the routine evaluation of patients prior to bariatric surgery is not covered as it is not known to be effective in improving health outcomes. Please see Polysomnography – Sleep Studies policy for coverage criteria. C. Esophagogastroduodenoscopy (EGD) performed as part of the routine evaluation of patients prior to bariatric surgery is not covered as it is not known to be effective in improving health outcomes.

IV. Administrative Guidelines Precertification is required. To precertify for procedure and place of treatment, please complete HMSA's Precertification Request and mail or fax the form as indicated.

Click for Metropolitan Life Tables

Bariatric Surgery 4

CPT Codes Description 43644 , surgical, gastric restrictive procedure; with gastric bypass and Roux- en-Y (roux limb 150 cm or less) 43645 with gastric bypass and reconstruction to limit absorption 43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g. gastric band and subcutaneous port components) 43771 revision of adjustable gastric restrictive device component only 43772 removal of adjustable gastric restrictive device component only 43773 removal and replacement of adjustable gastric restrictive device component only

43774 removal of adjustable gastric restrictive device and subcutaneous port components 43775 longitudinal gastrectomy (i.e., sleeve gastrectomy) 43842 Gastric restrictive procedure, without gastric bypass for morbid obesity; vertical- banded gastroplasty 43843 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 ) 43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy 43847 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 removal of subcutaneous port component only 43888 removal and replacement of subcutaneous port component only 43999 Unlisted procedure, HCPCS Description S2083 Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline

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ICD-9 Description Procedure Codes 43.41 Endoscopic excision or destruction of lesion or tissue of stomach 43.7 Partial gastrectomy with anastomosis to jejunum (biliopancreatic diversion) 43.82 Laparoscopic vertical (sleeve) gastrectomy 43.89 Other partial gastrectomy (biliopancreatic diversion with duodenal switch and sleeve gastrectomy) 44.31 High gastric bypass 44.38 Laparoscopic vertical (sleeve) gastrectomy 44.39 Other gastroenterostomy without gastrectomy 44.5 Revision of gastric anastomosis 44.68 Laparoscopic gastroplasty 44.69 Other repair of stomach 44.95 – Laparoscopic gastric restrictive procedure ( and port) code 44.98 range

ICD-10 codes are provided for your information. These will not become effective until October 1, 2015.

ICD-10 Description Procedure Codes 0D160ZA Bypass Stomach to Jejunum, Open Approach 0D164ZA Bypass Stomach to Jejunum, Percutaneous Endoscopic Approach 0D168ZA Bypass Stomach to Jejunum, Via Natural or Artificial Opening Endoscopic 0DB60ZZ Excision of Stomach, Open Approach 0DB63ZZ Excision of Stomach, Percutaneous Approach 0DB64ZZ Excision of Stomach, Percutaneous Endoscopic Approach 0DB67ZZ Excision of Stomach, Via Natural or Artificial Opening 0DB68ZZ Excision of Stomach, Via Natural or Artificial Opening Endoscopic 0DB64Z3 Excision of Stomach, Percutaneous Endoscopic Approach, Vertical 0DB60Z3 Excision of Stomach, Open Approach, Vertical 0DB60ZZ Excision of Stomach, Open Approach Bariatric Surgery 6

0DB63Z3 Excision of Stomach, Percutaneous Approach, Vertical 0DB63ZZ Excision of Stomach, Percutaneous Approach 0DB67Z3 Excision of Stomach, Via Natural or Artificial Opening, Vertical 0DB67ZZ Excision of Stomach, Via Natural or Artificial Opening 0DB68Z3 Excision of Stomach, Via Natural or Artificial Opening Endoscopic, Vertical 0D1607A Bypass Stomach to Jejunum with Autologous Tissue Substitute, Open Approach 0D160JA Bypass Stomach to Jejunum with Synthetic Substitute, Open Approach 0D160KA Bypass Stomach to Jejunum with Nonautologous Tissue Substitute, Open Approach 0D160ZA Bypass Stomach to Jejunum, Open Approach 0D1687A Bypass Stomach to Jejunum with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0D168JA Bypass Stomach to Jejunum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic 0D168KA Bypass Stomach to Jejunum with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0D168ZA Bypass Stomach to Jejunum, Via Natural or Artificial Opening Endoscopic 0D16479 Bypass Stomach to Duodenum with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0D1647A Bypass Stomach to Jejunum with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0D1647B Bypass Stomach to Ileum with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0D1647L Bypass Stomach to Transverse Colon with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0D164J9 Bypass Stomach to Duodenum with Synthetic Substitute, Percutaneous Endoscopic Approach 0D164JA Bypass Stomach to Jejunum with Synthetic Substitute, Percutaneous Endoscopic Approach 0D164JB Bypass Stomach to Ileum with Synthetic Substitute, Percutaneous Endoscopic Approach 0D164JL Bypass Stomach to Transverse Colon with Synthetic Substitute, Percutaneous Endoscopic Approach 0D164K9 Bypass Stomach to Duodenum with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach Bariatric Surgery 7

0D164KA Bypass Stomach to Jejunum with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0D164KB Bypass Stomach to Ileum with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0D164KL Bypass Stomach to Transverse Colon with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0D164Z9 Bypass Stomach to Duodenum, Percutaneous Endoscopic Approach 0D164ZA Bypass Stomach to Jejunum, Percutaneous Endoscopic Approach 0D164ZB Bypass Stomach to Ileum, Percutaneous Endoscopic Approach 0D164ZL Bypass Stomach to Transverse Colon, Percutaneous Endoscopic Approach 0D16079 Bypass Stomach to Duodenum with Autologous Tissue Substitute, Open Approach 0D1607A Bypass Stomach to Jejunum with Autologous Tissue Substitute, Open Approach 0D1607B Bypass Stomach to Ileum with Autologous Tissue Substitute, Open Approach 0D1607L Bypass Stomach to Transverse Colon with Autologous Tissue Substitute, Open Approach 0D160J9 Bypass Stomach to Duodenum with Synthetic Substitute, Open Approach 0D160JA Bypass Stomach to Jejunum with Synthetic Substitute, Open Approach 0D160JB Bypass Stomach to Ileum with Synthetic Substitute, Open Approach 0D160JL Bypass Stomach to Transverse Colon with Synthetic Substitute, Open Approach 0D160K9 Bypass Stomach to Duodenum with Nonautologous Tissue Substitute, Open Approach 0D160KA Bypass Stomach to Jejunum with Nonautologous Tissue Substitute, Open Approach 0D160KB Bypass Stomach to Ileum with Nonautologous Tissue Substitute, Open Approach 0D160KL Bypass Stomach to Transverse Colon with Nonautologous Tissue Substitute, Open Approach 0D160Z9 Bypass Stomach to Duodenum, Open Approach 0D160ZA Bypass Stomach to Jejunum, Open Approach 0D160ZB Bypass Stomach to Ileum, Open Approach 0D160ZL Bypass Stomach to Transverse Colon, Open Approach 0D16879 Bypass Stomach to Duodenum with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic Bariatric Surgery 8

0D1687A Bypass Stomach to Jejunum with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0D1687B Bypass Stomach to Ileum with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0D1687L Bypass Stomach to Transverse Colon with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0D168J9 Bypass Stomach to Duodenum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic 0D168JA Bypass Stomach to Jejunum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic 0D168JB Bypass Stomach to Ileum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic 0D168JL Bypass Stomach to Transverse Colon with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic 0D168K9 Bypass Stomach to Duodenum with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0D168KA Bypass Stomach to Jejunum with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0D168KB Bypass Stomach to Ileum with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0D168KL Bypass Stomach to Transverse Colon with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0D168Z9 Bypass Stomach to Duodenum, Via Natural or Artificial Opening Endoscopic 0D168ZA Bypass Stomach to Jejunum, Via Natural or Artificial Opening Endoscopic 0D168ZB Bypass Stomach to Ileum, Via Natural or Artificial Opening Endoscopic 0D168ZL Bypass Stomach to Transverse Colon, Via Natural or Artificial Opening Endoscopic 0DQ60ZZ Repair Stomach, Open Approach 0DQ63ZZ Repair Stomach, Percutaneous Approach 0DQ64ZZ Repair Stomach, Percutaneous Endoscopic Approach 0DQ67ZZ Repair Stomach, Via Natural or Artificial Opening 0DQ68ZZ Repair Stomach, Via Natural or Artificial Opening Endoscopic 0DQ64ZZ Repair Stomach, Percutaneous Endoscopic Approach 0DV64CZ Restriction of Stomach with Extraluminal Device, Percutaneous Endoscopic Approach Bariatric Surgery 9

0D760DZ Dilation of Stomach with Intraluminal Device, Open Approach 0D760ZZ Dilation of Stomach, Open Approach 0D763DZ Dilation of Stomach with Intraluminal Device, Percutaneous Approach 0D763ZZ Dilation of Stomach, Percutaneous Approach 0D764DZ Dilation of Stomach with Intraluminal Device, Percutaneous Endoscopic Approach 0D764ZZ Dilation of Stomach, Percutaneous Endoscopic Approach 0D767DZ Dilation of Stomach with Intraluminal Device, Via Natural or Artificial Opening 0D767ZZ Dilation of Stomach, Via Natural or Artificial Opening 0D768DZ Dilation of Stomach with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0D768ZZ Dilation of Stomach, Via Natural or Artificial Opening Endoscopic 0DF60ZZ Fragmentation in Stomach, Open Approach 0DF63ZZ Fragmentation in Stomach, Percutaneous Approach 0DF64ZZ Fragmentation in Stomach, Percutaneous Endoscopic Approach 0DF67ZZ Fragmentation in Stomach, Via Natural or Artificial Opening 0DF68ZZ Fragmentation in Stomach, Via Natural or Artificial Opening Endoscopic 0DM60ZZ Reattachment of Stomach, Open Approach 0DM64ZZ Reattachment of Stomach, Percutaneous Endoscopic Approach 0DN60ZZ Release Stomach, Open Approach 0DN63ZZ Release Stomach, Percutaneous Approach 0DN64ZZ Release Stomach, Percutaneous Endoscopic Approach 0DN67ZZ Release Stomach, Via Natural or Artificial Opening 0DN68ZZ Release Stomach, Via Natural or Artificial Opening Endoscopic 0DQ60ZZ Repair Stomach, Open Approach 0DQ63ZZ Repair Stomach, Percutaneous Approach 0DQ67ZZ Repair Stomach, Via Natural or Artificial Opening 0DQ68ZZ Repair Stomach, Via Natural or Artificial Opening Endoscopic 0DU607Z Supplement Stomach with Autologous Tissue Substitute, Open Approach 0DU60JZ Supplement Stomach with Synthetic Substitute, Open Approach 0DU60KZ Supplement Stomach with Nonautologous Tissue Substitute, Open Approach 0DU647Z Supplement Stomach with Autologous Tissue Substitute, Percutaneous Bariatric Surgery 10

Endoscopic Approach 0DU64JZ Supplement Stomach with Synthetic Substitute, Percutaneous Endoscopic Approach 0DU64KZ Supplement Stomach with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0DU677Z Supplement Stomach with Autologous Tissue Substitute, Via Natural or Artificial Opening 0DU67JZ Supplement Stomach with Synthetic Substitute, Via Natural or Artificial Opening 0DU67KZ Supplement Stomach with Nonautologous Tissue Substitute, Via Natural or Artificial Opening 0DU687Z Supplement Stomach with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0DU68JZ Supplement Stomach with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic 0DU68KZ Supplement Stomach with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0DV60CZ Restriction of Stomach with Extraluminal Device, Open Approach 0DV60DZ Restriction of Stomach with Intraluminal Device, Open Approach 0DV60ZZ Restriction of Stomach, Open Approach 0DV63CZ Restriction of Stomach with Extraluminal Device, Percutaneous Approach 0DV63DZ Restriction of Stomach with Intraluminal Device, Percutaneous Approach 0DV63ZZ Restriction of Stomach, Percutaneous Approach 0DV64DZ Restriction of Stomach with Intraluminal Device, Percutaneous Endoscopic Approach 0DV64ZZ Restriction of Stomach, Percutaneous Endoscopic Approach 0DV67ZZ Restriction of Stomach, Via Natural or Artificial Opening 0DV68ZZ Restriction of Stomach, Via Natural or Artificial Opening Endoscopic 0DV64CZ Restriction of Stomach with Extraluminal Device, Percutaneous Endoscopic Approach 0DW643Z Revision of Infusion Device in Stomach, Percutaneous Endoscopic Approach 0DW64CZ Revision of Extraluminal Device in Stomach, Percutaneous Endoscopic Approach 0DP643Z Removal of Infusion Device from Stomach, Percutaneous Endoscopic Approach 0DP64CZ Removal of Extraluminal Device from Stomach, Percutaneous Endoscopic Approach Bariatric Surgery 11

3E0G3GC Introduction of Other Therapeutic Substance into Upper GI, Percutaneous Approach

V. Important Reminder The purpose of this Medical Policy is to provide a guide to coverage. This Medical Policy is not intended to dictate to providers how to practice medicine. Nothing in this Medical Policy is intended to discourage or prohibit providing other medical advice or treatment deemed appropriate by the treating physician. Benefit determinations are subject to applicable member contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control. This Medical Policy has been developed through consideration of the medical necessity criteria under Hawaii’s Patients’ Bill of Rights and Responsibilities Act (Hawaii Revised Statutes §432E-1.4), generally accepted standards of medical practice and review of medical literature and government approval status. HMSA has determined that services not covered under this Medical Policy will not be medically necessary under Hawaii law in most cases. If a treating physician disagrees with HMSA’s determination as to medical necessity in a given case, the physician may request that HMSA reconsider the application of the medical necessity criteria to the case at issue in light of any supporting documentation.

VI. References 1. American Gastroenterological Association. Medical position statement on obesity. Gastroenterology. Sept. 2002; 123(3):879-881. 2. American Society for Metabolic and Bariatric Surgery (ASMBS) 29th Annual Meeting: Abstract PL 103. Presented June 20, 2012. 3. American Society for Metabolic and Bariatric Surgery. Statement/Guidelines: Bariatric surgery in class 1 obesity (body mass index 30–35kg/m2). Surgery for obesity and Related Diseases 9 (2013) e1 – e10. 4. American Society for Metabolic and Bariatric Surgery. Updated position statement on sleeve gastrectomy as a bariatric procedure. Draft Revised; October 14, 2011. 5. HMSA Guide to Benefits, 2013. 6. Ikramuddin S, Korner J, Lee WJ et al. Roux-en-Y gastric bypass vs. intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. JAMA 2013; 309(21):2240-9. 7. Medical Policy Reference Manual. Blue Cross and Blue Shield Association. Bariatric Surgery, Policy #7.01.47; September 2013 draft. Blue Cross Blue Shield Association. Technology Evaluation Committee. Laparoscopic Adjustable Gastric Banding for Morbid Obesity. February 2007. 8. Blue Cross and Blue Shield Association. Technology Evaluation Committee. Bariatric Surgery in Patients with Diabetes and Body Mass Index Less Than 35 kg/m2. 2012. 9. NIH Consensus Development Conference Statement. Gastrointestinal surgery for morbid obesity. March 1991; 9:1-20. Bariatric Surgery 12

10. The American Society for Metabolic and Bariatric Surgery. Updated position statement on sleeve gastrectomy as a bariatric procedure. Revised 2009. Surgery for Obesity and Related Diseases. 2010 Jan-Feb 6(1):1-5. Position Statement.