Effective Date:

1.     This policy will apply to all services performed on or after the above revision date which will become the new effective date.

2.     For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    This policy is specific to the Federal Employees Health Benefits.
 Consult your FEHBP plan for more details.

2)    Obesity surgery also known as bariatric surgery requires pre-authorization for this group.

1)    This policy applies only to members covered by the Federal Employees Health Benefits Program medical plan. For members of all other groups, please see the appropriate Medical Policy.

2)    Under the Federal Employees Health Benefits Program, Obesity (Bariatric) surgery requires preauthorization.

3)    General Selection criteria: Must meet all criteria 1 through 5

a)    Presence of severe obesity that has persisted for at least 3 years, defined as any of the following:

i)     Body mass index (BMI) (see notes) exceeding 40 (Z68.41-Z68.45); or

ii)    BMI  greater than 35 (Z68.35-Z68.39) in conjunction with any of the following severe co-morbidities:

(1)  Coronary heart disease (I20.8-I25.9); or

(2)  Diabetes mellitus (E11.0-E11.9); or

(3)  Clinically significant obstructive sleep apnea (G47.33); or

(4)  Medically refractory hypertension (I10-I15.9) (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management) and;

b)    Member must be between the ages of 18-64; and.

c)    Have a documented length of condition of at least 3 years; and,

d)    The member has had a psychological evaluation by a qualified mental health clinician, which may include but is not limited to a psychiatrist or psychologist; and

e)    Member must meet one of following:

i)     Member has participated in clinically supervised nutrition and exercise program (including dietician consultation, low calorie diet, exercise counseling, and behavioral modification, and pharmacologic therapy, if appropriate), documented in the medical record. This clinically-supervised nutrition and exercise program must meet all of the following criteria:

(1)  Nutrition and exercise program must be supervised and monitored in a clinical setting and working in cooperation with dieticians and/or nutritionists; and

(2)  Nutrition and exercise program(s) must be for a cumulative total of 12 months or longer in duration and occur within 2 years prior to surgery. and

ii)    Proximate to the time of surgery, member must participate in organized multidisciplinary surgical preparatory regimen of at least three months duration in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member`s ability to comply with post-operative medical care and dietary restrictions.

(1)  Examples of multidisciplinary Regimen.

(a)  Consultation with a dietician or nutritionist;

(b)  Reduced-calorie diet program supervised by dietician or nutritionist;

(c)  Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional;

(d)  Behavior modification program supervised by qualified professional;

(e)  Documentation in the medical record of the member`s participation in the multidisciplinary surgical preparatory regimen.

4)    Roux-en-Y Gastric Bypass (RYGB) and Laparoscopic Adjustable Silicone Gastric Banding (LASGB):

i)     Open or laparoscopic Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable silicone gastric banding (LASGB or Lap-Band) is considered medically necessary when the selection criteria above are met.

5)    Vertical Banded Gastroplasty (VBG):

i)     Open or laparoscopic vertical banded gastroplasty (VBG) is considered medically necessary for members who meet the selection criteria for obesity surgery and who are at increased risk of adverse consequences of a RYGB due to the presence of any of the following comorbid medical conditions:

b)    Hepatic cirrhosis with elevated liver function tests (K74.0, K74.60 - K74.69, R94.5); or

c)    Inflammatory bowel disease (Crohn`s disease or ulcerative colitis) (K50.00 - K51.919); or

d)    Radiation enteritis (K52.0); or

e)    Demonstrated complications from extensive adhesions involving the intestines from prior major abdominal surgery, multiple minor surgeries, or major trauma; or

f)     Poorly controlled systemic disease (American Society of Anesthesiology (ASA) Class IV).

6)    Repeat Bariatric Surgery:

Repeat bariatric surgery is considered medically necessary when the initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria), and when either of the following medical necessity criteria is met:

a)    Conversion to a RYGB may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or

b)    Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the procedure

7)    Elective cholecystectomy at the time of the covered obesity surgery will be covered.

Notes:
Calculation of BMI:
BMI is calculated by dividing the patient`s weight (in kilograms) by height (in meters) squared:
BMI = weight (kg) * [height (m)] 2
to convert pounds to kilograms, multiply pounds by 0.45. To convert inches to meters, multiply inches by 0.0254.
A BMI calculation module can be found here:

https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

Codes Used In This BI:

1)    Members who have a history of severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications, a pre-operative psychological evaluation and clearance is necessary in order to exclude members who are unable to provide informed consent or who are unable to comply with the pre- and postoperative regimen.

2)    Surgery to correct complications from bariatric surgery, such as obstruction or stricture, wound infections or hernias is covered only when the original bariatric surgery was (is) eligible for coverage.

3)    Obesity surgery for members under 18 is not covered as the safety and effectiveness have not been adequately documented 1

4)    Any of the following procedures are considered experimental and investigational because the peer reviewed medical literature shows them to be either unsafe or inadequately studied:

a)    Loop gastric bypass

b)    Gastroplasty, more commonly known as “stomach stapling” (see below for clarification from vertical band gastroplasty)

c)    Sleeve gastrectomy

d)    Duodenal switch operation

e)    Biliopancreatic bypass (Scopinaro procedure)

f)     Mini gastric bypass

g)    Silastic ring vertical gastric bypass (Fobi pouch)

h)   Intragastric balloon

i)     VBG, except in limited circumstances noted above.

1)    Hayes; Bariatric Surgery for Pediatric Morbid Obesity [revised 02.22.06].

2)    Arkansas BlueCross BlueShield Coverage Policy Manual; Gastric Restrictive or Bypass Surgery for Morbid (Clinically Severe) Obesity at: www.arkblucross.com.

3)    Harby K. Adjustable band obesity surgery successful in outpatients. Medscape Medical News, May 17, 2004 (reporting on Digestive Disease Week 2004 abstracts M1953 and M1944, presented May 17, 2004). Available at: www.medscape.com.

4)    American Medical Association. Diagnostic and therapeutic technology assessment. Garren gastric bubble. JAMA. 1986; 256(23):3282-3284.

5)    Jain A. What works for obesity? A summary of the research behind obesity interventions. London, UK: BMJ Publishing Group; April 30, 2004.

6)    Canadian Coordinating Office of Health Technology Assessment (CCOHTA). Laparoscopic adjustable gastric banding for clinically severe obesity. Pre-assessment No. 20. Ottawa, ON: CCOHTA; April 2003.

7)    Lee WJ, Huang MT, Yu PJ, et al. Laparoscopic vertical banded gastroplasty and laparoscopic gastric bypass: A comparison. Obes Surg. 2004; 14(5):626-634.

8)    Blanco-Engert R, Weiner S, Pomhoff I, et al. Outcome after laparoscopic adjustable gastric banding, uses the Lap-Band and the Heliogast band: A prospective randomized study. Obes Surg. 2003; 13(5):776-779.

9)    Brechner RJ, Farris C, Harrison S, et al. Bariatric Surgery. Summary of Evidence. Baltimore, MD: CMS; November 4, 2004.

10) Technology Assessment Unit, Office of Patient Care Services, U.S. Department of Veterans Affairs, Office of Patient Care Services, Technology Assessment Unit (VATAP). Bariatric surgery: Summary of INAHTA reviews. Boston, MA: VATAP; 2003.

11) Avenell A, Broom J, Brown TJ, et al. Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement. Health Technol Assess. 2004; 8(21):1-182.

12) Chapman AE. Kiroff G. Game P, et al. Laparoscopic adjustable gastric banding in the treatment of obesity: A systematic literature review. Surgery. 2004; 135(3):326-351.

13) Tice JA. Laparoscopic gastric banding for the treatment of morbid obesity. Technology Assessment. San Francisco, CA: California Technology Assessment Forum; June 9, 2004. Available at: www.ctaf.org.  Accessed March 4, 2005.

14) Tice JA. Duodenal switch procedure for the treatment of morbid obesity. Technology Assessment. San Francisco, CA: California Technology Assessment Forum; February 11, 2004. Available at: www.ctaf.org/content/assessments. 

15) Ontario Ministry of Health and Long-Term Care, Medical Advisory Secretariat. Bariatric surgery. Health Technology Literature Review. Toronto, ON: Ontario Ministry of Health and Long-Term Care; January 2005. Available at: http://www.health.gov.on.ca/english/providers/program/mas/
reviews/review_baria_0105.html. Accessed March 24, 2005.

16) BlueCross BlueShield Association (BCBSA), Technology Evaluation Center (TEC). Laparoscopic gastric bypass surgery for morbid obesity. Technology Assessment in Press. Chicago, IL: BCBSA; November 2005. Available at: www.bcbs.com.

17) Centers for Medicare and Medicaid Services (CMS). Decision memo for bariatric surgery for the treatment of morbid obesity (CAG-00250R). Medicare Coverage Database. Baltimore, MD: CMS; February 21, 2006. Available at: www.cms.hhs.gov.  

Addendum:

Effective 06/01/2023: Updated evaluation criteria to not be exclusive to a psychiatrist.

This policy applies only to the Federal Employees Health Benefits Program Federal Employees Health Benefits Program medical plan – groups 27030 and 27130. For any other group number see policy BI 158.