Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool https://www.highmarkhealthoptions.com/providers/prior-auth-lookup

Procedures

Prior authorization is required.

The policy is applicable at the time surgery is requested. BMI and weight requirements apply at the time of the initial consultation with the bariatric surgeon.

The following bariatric procedures may be considered medically necessary for the surgical treatment of morbid obesity when ALL of the selection criteria are met. 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 post-surgery.  

Laparoscopic adjustable gastric banding using an FDA-approved adjustable gastric band is a second-tier procedure that should ONLY be performed when extenuating circumstances exist.

 

Selection Criteria for Adults

Bariatric surgery may be considered medically necessary for individuals aged 18 or over when ALL of the following criteria are met

·       The procedure is ONE or more of the following

o   Biliopancreatic bypass with duodenal switch (or open procedure for individuals with a BMI of 50 kg/m2 or greater)

o   Roux-en-Y gastric bypass (RYGB) (laparoscopic or open procedure)

o   Sleeve Gastrectomy (laparoscopic or open procedure)

NOTE: Sleeve gastrectomy is an eligible procedure as a first stage of a two-stage procedure or as a sole definitive procedure. For high BMI individuals in whom the duodenal switch may be difficult, it is reasonable to do a sleeve gastrectomy as the first stage of an intended two-stage duodenal switch. This does permit subsequent assessment of both the efficacy of the sleeve (to see whether the second stage is really needed), assessment of the compliance of the individual (to see whether the more complicated procedure is justified) or to examine the metabolic and nutritional effects of the sleeve (to see whether potential further metabolic derangements of the duodenal switch would make it unadvisable)

o   Laparoscopic adjustable gastric banding using an FDA approved adjustable gastric band when ALL of the following criteria are met

§  A contraindication to biliopancreatic bypass with duodenal switch, Rou-en-Y gastric bypass, and sleeve gastrectomy is documented in the medical record

·       The individual is morbidly obese as defined by ONE or more of the following

o   A weight which is at least 100 lbs. or 100% over ideal weight

o   A BMI of at least 40 kg/m2

o   A BMI of 33 kg/m2 with ONE or more of the following

§  Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite concurrent use of three (3) anti-hypertensive agents of different classes)

§  Cardiovascular heart disease (with objective documentation by exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure or prior myocardial infarction)

§  Coronary heart disease (with objective documentation (by exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure, or prior myocardial infarction)

§  Hyperlipidemia (above 30mg/dl above guideline-directed goal) on maximum doses of monotherapy

§  Diabetes mellitus type II with glycosylated hemoglobin (HbA1C) above 8.0% on one or more medications

§  Obstructive sleep apnea (OSA) (diagnosed by polysomnography showing apnea-hypopnea index of 15 events/hour or more)

§  Obesity-hypoventilation syndrome (OHS)

§  Pickwickian syndrome (a combination of OSA and OHS)

§  Nonalcoholic fatty liver disease (NAFLD)

§  Pseudotumor Cerebri

§  Nonalcoholic steatohepatitis (NASH)

• The individual has documented failure to respond to conservative measures for weight reduction for a period of at least six (6) consecutive months prior to consideration of bariatric surgery, and these attempts should be reviewed by the practitioner prior to seeking approval for the surgical procedure (Conservative measures include changes to the individual’s dietary and exercise regimen)
• The individual has completed a multidisciplinary evaluation including medical, nutritional, and psychological evaluations. The individual's medical record documentation should indicate that all psychosocial issues have been identified and addressed
• The individual understands the procedure and has the ability to participate and comply with life-long follow-up and the life-style changes (e.g., changes in dietary habits, and beginning an exercise program)

If the individual does not meet ALL of the selection criteria for bariatric surgery, the procedure will be denied as not medically necessary.

Bariatric procedures not meeting the criteria as indicated in this policy are considered not medically necessary.

 

Selection Criteria for Adolescents

The eligible bariatric surgical procedures listed above unless otherwise specified are covered for individuals under the age of 18 years when they meet ALL of the following criteria:

• Attainment or near-attainment of physiologic/skeletal maturity at approximately, age 13 in girls and 15 for boys. (The individual has attained Tanner 4 pubertal development and final or near-final adult height (e.g., 95 % or greater) of adult stature); and
• The individual is morbidly obese defined as a BMI greater than 50 kg/m2  or severely obese defined as a BMI greater than 40 kg/m2 with ANY ONE or more obesity-related comorbidities:
  • Hypertension; or
  • Insulin resistance; or
  • Glucose intolerance; or
  • Dyslipidemia; or
  • Clinically significant OSA; or  
  • Substantially impaired quality of life or activities of daily living; or
• A BMI between 35-40 kg/m2 in addition to ONE or more serious obesity related comorbidities:
  • Type II diabetes; or
  • Moderate to severe OSA (apnea-hypopnea index greater than 15); or
  • Pseudotumor cerebri; or
  • NASH; and
• Individuals should have documented failure to respond to conservative measures for weight reduction prior to consideration of bariatric surgery, and these attempts should be reviewed by the practitioner prior to seeking approval for the surgical procedure. As a result, some centers require active participation in a formal weight reduction program that includes frequent documentation of weight, dietary regimen, and exercise. However, there is a lack of evidence on the optimal timing, intensity and duration of nonsurgical attempts at weight loss, and whether a medical weight loss program immediately preceding surgery improves outcomes; and
• The individual must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery. The individual's medical record documentation should indicate that all psychosocial issues have been identified and addressed; and
• The individual must be able to show decisional capacity and maturity in the psychological evaluation and provide informed assent for surgical management; and
• The individual must be capable and willing to adhere to nutritional guidelines postoperatively; and
• The individual must have a supportive and committed family environment; and
• Selection criteria is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. The individual's understanding of the procedure and ability to participate and comply with life-long follow-up and the life-style changes (e.g., changes in dietary habits, and beginning an exercise program) are necessary to the success of the procedure. 

If the adolescent does not meet ALL of the adolescent selection criteria for bariatric surgery, the procedure will be denied as not medically necessary.

Bariatric procedures not meeting the criteria as indicated in this policy are considered not medically necessary.

Repeat or Revised Bariatric Surgical Procedures

Surgical repair to correct perioperative or late chronic complications of a bariatric procedure may be considered medically necessary when there is documentation of a surgical complication related to the perioperative or late chronic complications of a bariatric procedure. These include but are not limited to:

• Enteric fistula that does not close with bowel rest and nutritional support; or
• Gastrogastric fistula associated with ulcers, gastroesophageal reflux disease (GERD) and weight gain; or
• Band erosion; or
• Disruption/anastomotic leakage of a suture/staple line; or
• Tubing leak or port dislocation; or
• Small bowel obstruction; or
• Band intolerance with obstructive symptoms (e.g. vomiting, esophageal spasm); or
• Band slippage and/or prolapse that cannot be corrected with manipulation or adjustment; or
• Stricture/stenosis with dysphagia, solid food intolerance and/or severe reflux; or
• Stomal stenosis; or
• Refractory marginal ulcers; or
• Non-absorption resulting in hypocalcemia or malnutrition; or
• Weight loss of 20% or more below ideal body weight. 

Repeat surgical procedures for revision or conversion to another surgical procedure may be considered medically necessary when the initial bariatric surgery was medically necessary (and the individual continues to meet all the medical necessity criteria for bariatric surgery); and when ANY ONE of the following criteria is met:

• A conversion to a sleeve gastrectomy, RYGB or biliopancreatic bypass with duodenal switch (BPD/DS) for individuals who have not had adequate weight loss success (defined as less than 50% of excess body weight) two (2) years following the primary bariatric surgery procedure and the individual has been compliant with a prescribed nutrition and exercise program following the procedure; or

·         A revision of a primary bariatric surgery procedure that has failed due to dilatation of the gastric pouch, dilated gastrojejunal stoma, or dilation of the gastrojejunostomy (GJ)            anastomosis if the primary procedure was successful in inducing weight loss prior to the dilation of the pouch or GJ anastomosis, and the individual has been compliant with a            prescribed nutrition and exercise program following the procedure; or

·         Replacement of an adjustable band if there are complications (e.g., port leakage, slippage) that cannot be corrected with band manipulation or adjustments; or

·         A conversion from an adjustable band to a sleeve gastrectomy, RYGB or BPD/DS for individuals who have been compliant with a prescribed nutrition and exercise program            following the band procedure and have experienced complications that cannot be corrected with band manipulation, adjustments, or replacement. 

Individual postoperative noncompliance negates the efficacy of revision or conversion surgery.

Conversion or revision surgery is considered not medically necessary when due to inadequate weight loss related to non-compliance with post-operative nutrition and exercise recommendations.

Repeat procedures for repair, revision, or conversion to another surgical procedure following a gastric bypass or gastric restrictive procedure not meeting the criteria as indicated in this policy are considered not medically necessary.

 

The following bariatric procedures are considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

• Endoscopic procedures including but not limited to;
  • StomaphyX™ device or restorative obesity surgery (ROSE) procedure; or
  • Aspiration therapy devices; or
  • Endoscopic gastroplasty; or
  • Gastrointestinal Liners (e.g., the EndoBarrier); or
  • Gastric balloons; or
  • Transoral outlet reduction (TORe); or
• Biliopancreatic bypass (the Scopinaro procedure) or laparoscopic; or
• The long-limb gastric bypass; or
• Intestinal bypass; or
• Laparoscopic gastric plication; or
• Vagal nerve blocking (VBLOC) therapy (neuromodulation non-metabolic), also known as the Maestro implant or Maestro rechargeable system; or
• Mini-gastric bypass; or
• Vertical banded gastroplasty

Post-payment Audit Statement

The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by Highmark Health Options at any time pursuant to the terms of your provider agreement.

 

Place of Service: Inpatient/Outpatient

These procedures may be performed as either an inpatient or outpatient depending upon the individual patient’s condition or comorbidities.

 

REIMBURSEMENT

Participating facilities will be reimbursed per their Highmark Health Options contract.