Medical Coverage Policy Effective Date ............................................12/15/2020 Next Review Date ....................................... 7/15/2021 Coverage Policy Number .................................. 0051 Bariatric Surgery and Procedures Table of Contents Related Coverage Resources Overview ................................................................... 2 Gastric Pacing/Gastric Electrical Stimulation (GES) Coverage Policy ....................................................... 2 Obstructive Sleep Apnea Treatment Services Adults ..................................................................... 2 Panniculectomy and Abdominoplasty Bariatric Surgery Procedures (Adults) ................ 3 Sleep Testing Services Reoperation and Revisional Bariatric Surgery Vagus Nerve Stimulation (VNS) (Adults) ............................................................... 4 Adolescents ............................................................ 5 Bariatric Surgery Procedures (Adolescents) ...... 5 Reoperation and Revisional Bariatric Surgery (Adolescents) ...................................................... 6 Adults and Adolescents.......................................... 6 Bariatric Surgery for the Treatment of Diabetes Mellitus ............................................................... 6 Cholecystectomy, Liver Biopsy, Herniorrhaphy, Prophylactic Vena Cava Filter Placement, or Upper Endoscopy ............................................... 6 General Background ............................................... 7 Bariatric Surgery Procedures ........................... 13 Other Bariatric Surgical Procedures ................. 18 Reoperation/Revisional Bariatric Surgery ........ 44 Bariatric Surgery for the Treatment of Diabetes Mellitus (DM) .................................................... 45 Cholecystectomy, Liver Biopsy, Herniorrhaphy, Prophylactic Vena Cava Filter Placement, or Upper Endoscopy ............................................. 50 Medicare Coverage Determinations .................... 57 Coding/Billing Information.................................... 57 References ............................................................. 62 INSTRUCTIONS FOR USE The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for Page 1 of 84 Medical Coverage Policy: 0051 treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations. Overview This Coverage Policy addresses bariatric surgery and procedures for the treatment of morbid obesity. Coverage Policy Coverage for bariatric surgery or revision of a bariatric surgery procedure varies across plans and may be governed by state mandates. Refer to the customer’s benefit plan document for coverage details. This coverage policy statement is organized as follows: 1) Criteria that applies to Adults only 2) Criteria that applies to Adolescents only 3) Criteria that applies to Adults and Adolescents Adults Bariatric surgery for the treatment of morbid obesity in an adult (age ≥ 18 years) using a covered procedure outlined below is considered medically necessary when ALL of the following criteria are met: • EITHER of the following: BMI (Body Mass Index) ≥ 40 BMI (Body Mass Index) 35–39.9 with at least one clinically significant obesity-related comorbidity, including but not limited to the following: o mechanical arthropathy in a weight-bearing joint (symptomatic degenerative joint disease in a weight bearing joint) o diabetes mellitus o poorly controlled hypertension (systolic blood pressure at least 140 mm Hg or diastolic blood pressure 90 mm Hg or greater, despite optimal medical management) o hyperlipidemia o coronary artery disease o lower extremity lymphatic or venous obstruction o obstructive sleep apnea o pulmonary hypertension o evidence of fatty liver disease (i.e., nonalcoholic fatty liver disease [NAFLD] or nonalcoholic steatohepatitis [NASH]) • A statement from a physician/physician assistant/nurse practitioner/licensed mental health provider/registered dietician that the individual has failed previous attempts to achieve and maintain weight loss by medical management. • A thorough multidisciplinary evaluation within the previous six months which includes ALL of the following: a description of the proposed procedure(s) a recommendation for bariatric surgery from a physician/ physician assistant/nurse practitioner other than the requesting surgeon or associated staff unequivocal clearance for bariatric surgery by a mental health provider a nutritional evaluation by a physician, physician assistant, nurse practitioner or registered dietician Page 2 of 84 Medical Coverage Policy: 0051 Bariatric Surgery Procedures (Adults) When the specific medical necessity criteria noted above for bariatric surgery for an adult have been met, ANY of the following open or laparoscopic bariatric surgery procedures for the treatment of morbid obesity is considered medically necessary: Procedure Open CPT® Codes Laparoscopic CPT® Codes Vertical band gastroplasty 43842 43659 Adjustable silicone gastric banding (e.g., LAP- 43843 43770 ® ™ BAND , REALIZE ) Sleeve gastrectomy as a stand-alone or 43843 43775 staged procedure Roux-en-Y gastric bypass 43846 43644 (roux limb less than 150 cm) Roux-en-Y gastric bypass 43847 43645 (roux limb greater than 150 cm) Biliopancreatic Diversion with Duodenal 43845 43659, 44799 Switch (BPD/DS) Billiopancreatic Diversion (BPD) without DS 43633 43659 Adjustment of a silicone gastric banding is considered medically necessary to control the rate of weight loss and/or treat symptoms secondary to gastric restriction following a medically necessary adjustable silicone gastric banding procedure. The following bariatric surgery procedures for the treatment of morbid obesity, when performed alone or in conjunction with another bariatric surgery procedure are considered experimental, investigational or unproven: Procedure CPT® Code(s) Band over bypass 43770, 43843, 43999 Band over sleeve 43770, 43843, 43999 Fobi-Pouch (limiting proximal gastric pouch) 43659, 43843, 43999 Gastric electrical stimulation (GES) or gastric pacing 64590 and 43881 OR 64590 and 43647 Gastroplasty (stomach stapling) 43659, 43843 Intestinal bypass (jejunoileal bypass) 44238, 44799 Intragastric balloon (e.g., Orbera™, ReShape™, Obalon) 43999 Laparoscopic greater curvature plication 43659 Loop gastric bypass 43659, 43843 Mini-gastric bypass 43659, 43843 Natural Orifice Transluminal Endoscopic Surgery 43289, 43499 (NOTES)/endoscopic oral-assisted bariatric surgery procedures, including but not limited to the following: restorative obesity surgery, endoluminal (ROSE) StomaphyX™, duodenojejunal bypass liner (e.g., Endobarrier™) transoral gastroplasty (e.g., TOGA®) endoscopic closure devices (e.g., Apollo OverStitch™) Roux-en-Y gastric bypass combined with simultaneous 43644 or 43645 and 43770 gastric banding OR Page 3 of 84 Medical Coverage Policy: 0051 43846 or 43847 and 43843 or 43999 Single-anastomosis duodenal switch (DS) 43659, 43999, 44799 ® Stomach aspiration therapy (e.g., AspireAssist ) 43659, 43999 ® Vagus nerve blocking (e.g., Maestro ) 0312T, 0313T, 0316T, 0317T Vagus nerve stimulation 61885 and 64568 OR 61885 and 64553 Reoperation and Revisional Bariatric Surgery (Adults) Replacement of an adjustable silicone gastric band or separate or concurrent band removal and conversion to a second bariatric surgical procedure is considered medically necessary if there is evidence of band slippage or band component malfunction and the faulty component cannot be repaired. Gastric band removal is considered medically necessary for gastrointestinal symptomology (e.g., persistent nausea and/or vomiting, gastroesophageal reflux) with or without imaging evidence of obstruction. The following procedures are considered medically necessary when the individual develops a major complication from a primary bariatric surgery