Obesity is an increase in body weight beyond the limitation of skeletal and physical requirements, as a result of excessive accumulation of fat in the body. In general, 20% to 30% above "ideal" bodyweight, according to standard life insurance tables, constitutes obesity. Morbid obesity is further defined as a condition of consistent and uncontrollable weight gain that is characterized by a weight which is at least 100 lbs. or 100% over ideal weight or a body mass index (BMI) of at least 40 or a BMI of 35 with comorbidities.
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.
Selection Criteria for Adults
If the individual does not meet ALL of the selection criteria for bariatric surgery, the procedure will be denied as not medically necessary.
43644 |
43770 |
43775 |
43843 |
43845 |
43846 |
S2083 |
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:
If the adolescent does not meet ALL of the adolescent selection criteria for bariatric surgery, the procedure will be denied as not medically necessary.
43644 |
43770 |
43775 |
43843 |
43845 |
43846 |
|
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:
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:
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 are considered not medically necessary when the criteria listed above are not met.
43644 |
43771 |
43772 |
43773 |
43774 |
43775 |
43845 |
43846 |
43848 |
43886 |
43887 |
43888 |
|
|
The following bariatric procedures are considered experimental/investigational, and therefore, non-covered. There is insufficient evidence in the peer-reviewed published medical literature regarding effectiveness and safety of these procedures.
43645 |
43842 |
43847 |
43999 |
0312T |
0313T |
0314T |
0315T |
0316T |
0317T |
44799 |
|
|
|
Refer to Medical Policy S-155, Gastric Electrical Stimulation, Gastric Pacing, for additional information.
Covered Diagnosis Codes for Procedure Codes 43644, 43770, 43775, 43843, 43846, S2083
E66.01 |
Z68.35 |
Z68.36 |
Z68.37 |
Z68.38 |
Z68.39 |
Z68.41 |
Z68.42 |
Z68.43 |
Z68.44 |
Z68.45 |
Covered Diagnosis Codes for Procedure Codes 43845
E66.01 |
Z68.43 |
Z68.44 |
Z68.45 |
|
|
|
Non-Covered Diagnosis Codes
E66.1 |
E66.3 |
E66.8 |
E66.9 |
E66.09 |
|
|
The treatment of obesity is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.