Bariatric Surgery in Adults With Class 3 Obesity (BMI ≥40 kg/m2)
The following bariatric surgery procedures may be considered medically necessary for the treatment of class 3 obesity (BMI ≥40.0 kg/m2) in adults (ages 18 and older) who have failed weight loss by conservative measures:
Open or laparoscopic gastric bypass using a Roux-en-Y,
Laparoscopic adjustable gastric banding,
Open or laparoscopic sleeve gastrectomy (SG), and
Open or laparoscopic biliopancreatic bypass/diversion (ie, Scopinaro procedure) with duodenal switch (DS).
Bariatric Surgery in Adults With Class 2 Obesity (BMI ≥35 to 39.9 kg/m2)
The following bariatric surgery procedures may be considered medically necessary for the treatment of class 2 obesity in individuals with at least 1 obesity-related comorbid condition (see Policy Guidelines) who have failed weight loss by conservative measures:
Open or laparoscopic gastric bypass using a Roux-en-Y,
Laparoscopic adjustable gastric banding,
Open or laparoscopic sleeve gastrectomy (SG), and
Open or laparoscopic biliopancreatic bypass/diversion (ie, Scopinaro procedure) with duodenal switch (DS).
Bariatric surgery should be performed in appropriately selected individuals, by surgeons who are adequately trained and experienced in the specific techniques used, and in institutions that support a comprehensive bariatric surgery program, including long-term monitoring and follow-up postsurgery. (see Policy Guidelines for bariatric surgery selection criteria).
Bariatric Surgery in Individuals With Class 1 Obesity (BMI ≥30 to 34.9 kg/m2) and Type 2 Diabetes
For individuals with Class 1 obesity (BMI ≥30 to 34.9 kg/m2) and type 2 diabetes, the following bariatric surgery procedures may be considered medically necessary in adults who have failed weight loss by conservative measures:
Open or laparoscopic gastric bypass using a Roux-en-Y,
Laparoscopic adjustable gastric banding,
Open or laparoscopic sleeve gastrectomy (SG), and
Open or laparoscopic biliopancreatic bypass/diversion (ie, Scopinaro procedure) with duodenal switch (DS).
Bariatric surgery is considered investigational for individuals with Class 1 obesity who do not have type 2 diabetes.
Bariatric surgery is considered investigational for individuals with a BMI less than 30 kg/m2.
The following bariatric surgery procedures are considered investigational for the treatment of obesity: s:
Vertical-banded gastroplasty,
Gastric bypass using a Billroth II type of (mini-gastric bypass),
Biliopancreatic diversion (BPD) without DS,
Long-limb gastric bypass procedure (ie, >150 cm),
Two-stage bariatric surgery procedures (eg, SG as initial procedure followed by BPD at a later time),
Laparoscopic gastric plication, and
Single anastomosis duodeno-ileal bypass with SG.
Revision Bariatric Surgery
Revision surgery to address perioperative or late complications of a bariatric procedure is considered medically necessary. These include but are not limited to, staple line failure, obstruction, stricture, nonabsorption resulting in hypoglycemia or malnutrition, weight loss of 20% or more below ideal body weight, and band slippage that cannot be corrected with manipulation or adjustment (see Policy Guidelines section).
Revision of a primary bariatric procedure that has failed due to dilation of the gastric pouch or dilation proximal to an adjustable gastric band (documented by upper gastrointestinal examination or endoscopy) is considered medically necessary if the initial procedure was successful in inducing weight loss prior to pouch dilation, and the individual has been compliant with a prescribed nutrition and exercise program.
Revision surgery to address severe gastroesophageal reflux disease refractory to medical treatment is considered medically necessary.
Bariatric Surgery in Adolescents
Bariatric surgery in adolescents may be considered medically necessary according to similar weight-based criteria used for adults, but greater consideration should be given to psychosocial and informed consent issues (see Policy Guidelines section). In addition, any devices used for bariatric surgery must be used in accordance with the U.S. Food and Drug Administration approved indications.
Bariatric Surgery in Preadolescent Children
Bariatric surgery is considered investigational for the treatment of obesity in preadolescent children.
Concomitant Hiatal Hernia Repair With Bariatric Surgery
Repair of a hiatal hernia at the time of bariatric surgery may be considered medically necessary for individuals who have a preoperatively diagnosed hiatal hernia with indications for surgical repair (see Policy Guidelines section).
Repair of a hiatal hernia that is diagnosed at the time of bariatric surgery, or repair of a preoperatively diagnosed hiatal hernia in individuals who do not have indications for surgical repair is considered investigational.
Endoscopic Procedures
The following endoscopic procedures are investigational as a primary bariatric procedure or as a revision procedure (ie, to treat weight gain after bariatric surgery to remedy large gastric stoma or large gastric pouches):
Insertion of the StomaphyX™ device,
Endoscopic gastroplasty,
Use of an endoscopically placed duodenojejunal sleeve,
Intragastric balloons, and
Aspiration therapy device.
