a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

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

Please refer to your plan documents for coverage of obesity management programs and bariatric (weight loss) surgery.  

Obesity management programs and bariatric (weight loss) surgery require preauthorization.

It is the policy of QualChoice that an obesity management program (nutritional counseling for diet & exercise +/- medication) for adults is medically necessary when the following criteria are met:

Age > 18 years and BMI ≥ 30 kg/m² with no untreated, medically correctable cause of obesity (such as hypothyroidism).

Up to a combined total 8 units of the following codes will be allowed annually (See BI342):

97802 – 97803         Dietary Counseling, (1 unit = 15 mins)
98960 – 98962         Education and Training for patient self-management (1 unit = 30 mins)

99078                         Physician Educational Services

S9470                       Nutritional counseling, dietician visit

Allowed/covered weight loss medications include:

·         Metformin (off label—no PA required)

·         Topiramate (off label—no PA required)

·         Phentermine for up to 6 weeks—PA required and will need to document there are no contraindications to using

It is the policy of QualChoice that the bariatric surgery procedures LAGB, LSG, laparoscopic RYGB or laparoscopic BPD-DS/BPD-GRDS are medically necessary (along with elective cholecystectomy) when the following criteria under section I, II and III are met:

I. Medical history, meets all of the following:

Age > 18 years and (a, b or c):

a. Documented BMI ≥ 40 kg/m² for at least 3 years, or;

b. BMI ≥ 35 and < 40 kg/m² with at least one of the following comorbidities that is unimproved or poorly controlled despite 6 months of adherence to lifestyle and (when appropriate) pharmacotherapy management:

i. Type 2 diabetes mellitus (DM) on metformin and a GLP-1 agonist and/or SGLT2 inhibitor

ii. Poorly controlled hypertension

iii. Dyslipidemia

iv. Obstructive sleep apnea

v. Obesity-hypoventilation syndrome/Pickwickian syndrome

vi. Nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH)

vii. Asthma

viii. Venous stasis disease

ix. Severe urinary incontinence

x. Osteoarthritis (hip, knees and/or ankles)

xi. Pseudotumor cerebri (idiopathic intracranial hypertension)

xii. Psoriasis uncontrolled with topical agents and narrow band UVB

xiii. Psoriatic arthritis

xiv. Significant impairment of activities of daily living,

            c. Persistent obesity (BMI ≥ 40 kg/m² or BMI 35-39.9 kg/m² with comorbidities noted above) despite at least 6 months documented adherence to obesity management interventions (nutritional counseling for diet & exercise +/- medication).

II. Preoperative evaluation and medical clearance requirements within 6 months of the scheduled surgery include all of the following:

A. Cardiac evaluation includes an electrocardiogram and one of the following categories (1 or 2):

1. LOW CARDIAC RISK candidates, with none of the risk factors listed in section 2, need cardiac clearance by a PCP or cardiologist. If additional testing is needed, it should be conducted by a cardiologist.

2. HIGH CARDIAC RISK candidates need consultation/evaluation and cardiac clearance from a cardiologist. High risk candidates include those with any of the following:

a. History of ischemic heart disease;

b. History of congestive heart failure;

c. History of cerebrovascular disease;

d. Glomerular filtration rate < 30 mL/min-1;

e. High-grade arrhythmia;

f. Hemodynamically significant valvular heart disease.

B. To improve surgical outcomes, glycemic control should be optimized as evidenced by one of the following:

1. HbA1c 6.5 - 7.0%;

2. Fasting blood glucose level of ≤ 110 mg/dL;

3. 2-hour postprandial blood glucose concentration of ≤ 140 mg/dL;

4. HbA1c of 7 - 8% in candidates with advanced microvascular or macrovascular complications, extensive co-morbid conditions, or long-standing diabetes in which the general goal has been difficult to attain despite intensive efforts.

5. If one of the glycemic control criteria (above) are not met despite documented adherence to intensive efforts, an explanation of how the risks of not doing the surgery exceed the increased risk of surgical complications from poor glycemic control.

C. Pulmonary Evaluation:

1. Chest x-ray;

2. Screening for obstructive sleep apnea;

3. Pulmonary function testing and arterial blood gas analysis for candidates with intrinsic lung disease or disordered sleep patterns;

4. Evaluation of obstructive sleep apnea (HST or PSG—see BI306) in members who meet at least one of the following criteria:

a. Recurrent witnessed apnea during sleep > 10 seconds in duration;

b. Excessive or inappropriate daytime sleepiness such as falling asleep while driving or eating;

c. Sleepiness that interferes with daily activities not explained by other conditions, such as poor sleep hygiene, medication, drugs, alcohol, psychiatric or psychological disorders;

d. Having an Epworth Sleepiness Scale score > 10;

e. Persistent or frequent disruptive snoring, choking or gasping episodes associated with awakenings;

5. Specialist should be consulted for interpretation of any abnormal findings.

D. Nutritional evaluation, including micronutrient measurements and treatment of insufficiencies/deficiencies prior to surgery.

F. Nutritional therapy/counseling

1. Initial comprehensive diet history to include assessment of current pattern of nutrition and exercise and steps to modify problem eating behaviors;

2. Monthly nutritional counseling until the date of the surgery;

3. Prescribed exercise program;

4. Must provide documentation that counseling has been conducted regarding the potential for success of weight loss surgery dependent on post-op diet modification.

G. Psychiatry/psychology consultation including all of the following:

1. An in-person psychological evaluation to assess for major mental health disorders which would contradict surgery and determine ability to comply with post-operative care and guidelines;

2. If history is positive for alcohol or drug abuse must provide documentation of alcohol and drug abstinence for ≥ 1 year prior to surgery.

H. Members with signs or symptoms of hypothyroidism (other than obesity) are screened with a TSH level and treated if found to be hypothyroid.

I. A fasting lipid panel must be obtained and, if necessary, treatment initiated for dyslipidemia.

J. Screening for Helicobacter pylori if signs or symptoms of active peptic ulcer disease are present, with documentation of treatment if positive for H.pylori.

K. Prophylactic treatment for gouty attacks in patients with a history of gout.

L. If tobacco user, must stop use > 6 weeks prior to surgery (documented with negative urine cotinine testing).

III. Bariatric Surgery Accreditation

The bariatric surgery will be performed through a facility/program that has MBSAQIP accreditation (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program) through the American College of Surgeons. This requirement will not apply to members employed by The City of Hot Springs.

IV. Repeat Surgeries

A. Repeat bariatric surgery is considered medically necessary for one of the following:

1. To correct complications from a previous bariatric surgery, such as obstruction or strictures;

2. Conversion from LAGB to a RYGB or BPD-DS; or revision of a primary procedure that has failed due to dilation of the gastric pouch when all of the following criteria are met:

a. All criteria listed above for the initial bariatric procedure must be met again;

b. Previous surgery for morbid obesity was at least 3 years prior to repeat procedure;

c. Weight loss from the initial procedure was less than 50% of the member`s excess body weight at the time of the initial procedure;

d. Documented compliance with previously prescribed postoperative nutrition and exercise program. If non-compliant with postoperative regimen, member will be required to take part in an established multidisciplinary bariatric program to meet all of the initial surgery criteria listed above;

e. Supporting documentation from the provider should also include a clinical explanation of the circumstances as to why the procedure failed and if initial procedure failure was related to non-compliance with diet then why the requesting provider feels member will be compliant with diet after repeat surgery.

IV. Contraindications for surgical weight loss procedures include:

A. Medically correctable causes of obesity;

B. An ongoing substance abuse problem within the preceding year;

C. Untreated major depression or psychosis;

D. Uncontrolled and untreated eating disorders (eg, bulimia);

E. A medical, psychiatric, psychosocial, or cognitive condition that prevents adherence to post-operative dietary and medication regimens or impairs decisional capacity;

F. Current or planned pregnancy within 12 to 18 months of the procedure;

G. Severe cardiac disease with prohibitive anesthetic risks;

H. Severe coagulopathy;

I. Inability on the part of the patient to comprehend the risks and benefits of the surgical procedure.

Coding Implications

1) Members who have an uncontrolled severe psychiatric disorder or active substance use

disorder are not eligible.

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.  For panniculectomy see BI284.

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

not been adequately documented

4) Members with uncontrolled severe medical problems such as active cancer, severe heart

failure, or unstable angina may not be eligible until the medical condition is controlled.

5) 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) Biliopancreatic bypass without duodenal switch (Scopinaro procedure)

d) Mini gastric bypass;

e) Silastic ring vertical gastric bypass (Fobi pouch);

f) Intragastric balloon;

g)Distal gastric bypass (very long limb gastric bypass);

h) Laparoscopic re-sleeve gastrectomy (LRSG) performed after the resulting gastric pouch is primarily too large or dilates after the original LSG;

i) Laparoscopic greater curvature plication (Gastric Imbrication);

j) LAP-BAND when BMI is 30 to 35 with or without comorbid conditions;

k) AspireAssist;

H. Endoscopic Suture Revisions post bariatric surgery.

6) It is the policy of QualChoice that the following bariatric surgery procedures are considered not medically necessary, due to potential complications and a lack of positive outcomes:

A. Biliopancreatic diversion (BPD) procedure (also known as the Scopinaro procedure);

B. Jejunoileal bypass (jejuno-colic bypass);

C. Vertical Banded Gastroplasty (VBG);

D. Gastric balloon;

E. Gastric pacing;

F. Gastric wrapping.

AlSabah S, Alsharqawi N, Almulla A, et al. Approach to Poor Weight Loss After Laparoscopic Sleeve Gastrectomy: Re-sleeve Vs. Gastric Bypass. Obes Surg. 2016 Mar 14. [Epub ahead of print].

2. Buchwald H. Bariatric surgery for morbid obesity: Health implications for patients, health professionals, and third-party payers. 2004 American Society for Bariatric Surgery Consensus Conference Statement. Surgery for Obesity and Related Disease, 2005:1:371-381.

3. Centers for Medicare and Medicaid Services. National Coverage Determination (NCD) for Bariatric Surgery for Treatment of Morbid Obesity (100.1). Effective 9/24/13. Accessed 6/11/18.

4. Cohn SL. Evaluation of cardiac risk prior to noncardiac surgery. In: UpToDate, Pellikka PA (Ed), UpToDate, Waltham, MA. Accessed 6/13/18.

5. Colquitt J, Pickett K, Loveman E, Frampton GK. Surgery for weight loss in adults. Cochrane Database of Systematic Reviews, 2014. DOI: 10.1002/14651858.CD003641.pub4

6. Committee, ASMBS Clinical Issues. “Bariatric Surgery in Class I Obesity (Body Mass Index 30-35 kg/m2).” Surgery for Obesity and Related Diseases, vol. 9, no. 1, 2013, doi:10.1016/j.soard.2012.09.002.

7. Davis C, Tait G, Carroll J, Wijeysundera DN, Beattie WS. The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients. Can J Anaesth. 2013 Sep; 60(9):855-63.

8. Fried M, Dolezalova K, Sramkova P. Adjustable gastric banding outcomes with and without gastrogastric imbrication sutures: a randomized controlled trial. Surg Obes Relat Dis. 2011 Jan-Feb;7(1):23-31. doi: 10.1016/j.soard.2010.09.018. Epub 2010 Oct 30.

9. Hayes Medical Technology Directory. Intragastric balloons for the treatment of obesity. March 29, 2018. Accessed June 13, 2018.

10. Iannelli A, Schneck AS, Noel P, Ben Amor I, Krawczykowski D, Gugenheim J. Re-sleeve gastrectomy for failed laparoscopic sleeve gastrectomy: a feasibility study. Obes Surg. 2011 Jul;21(7):832-5. doi: 10.1007/s11695-010-0290-0.

11. Jensen MD, Ryan DH, Apovian CM, er al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol. 2014 Jul 1;63(25 Pt B):2985-3023.

12. Lim RB. Bariatric operations for management of obesity: Indications and preoperative preparation. In: UpToDate, Jones D (Ed), UpToDate, Waltham, MA. Accessed 06/11/18.

13. Lim RB. Bariatric procedures for the management of severe obesity: Descriptions. In: UpToDate, Jones D (Ed), UpToDate, Waltham, MA. Accessed 06/11/18.

14. Kim JJ, Rogers AM, Ballem N, Schirmer B. ASMBS updated position statement on insurance mandated preoperative weight loss requirements. Surg Obes Relat Dis. 2016 Jun;12(5):955-9. doi: 10.1016/j.soard.2016.04.019.

15. Mechanick JI, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient – 2013 update: Cosponsored by American Association of Clinical Endocrinologist, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surgery for Obesity and Related Diseases 9 (2013) 159-191.

16. National Institute of Diabetes and Digestive and Kidney Diseases. Bariatric Surgery. Updated July 2016. Accessed at: https://www.niddk.nih.gov/health-information/health-topics/weight-control/bariatric-surgery/Pages/all-content.aspxWIN. Accessed 06/11/18

17. Noren, Erik, and Henrik Forssell. “Aspiration Therapy for Obesity; a Safe and Effective Treatment.” BMC Obesity. 2016:3(1). doi:10.1186/s40608-016-0134-0.

18. Parikh M, Chung M, Sheth S, et al. Randomized pilot trial of bariatric surgery versus intensive medical weight management on diabetes remission in type 2 diabetic patients who do NOT meet NIH criteria for surgery and the role of soluble RAGE as a novel biomarker of success. Ann Surg. 2014;260(4):617-622; discussion 622-624.

19. Sharma S, Nararia M, Cottam DR, Cottam S. Randomized double-blinded trial of laparoscopic gastric imbrication v laparoscopic sleeve gastrectomy at a single Indian institution. Obes Surg. 2015 May;25(5):800-4. doi: 10.1007/s11695-014-1497-2.

20. Sugerman HJ, et al., Gastric bypass for treating severe obesity. Am J Clin Nutr, 1992. 55(2 Suppl): p. 550S-566S.

21. Svanevik M, Risstad H, Hofsø D, et al. Perioperative outcomes of proximal and distal gastric bypass in patients with BMI ranged 50-60 kg/m2 – a double-blind, randomized controlled trial. Obes Surg. 2015; 25(10): 1788–1795. doi: 10.1007/s11695-015-1621-y

22. Thompson, Christopher C, et al. “Percutaneous Gastrostomy Device for the Treatment of Class II and Class III Obesity: Results of a Randomized Controlled Trial.” The American Journal of Gastroenterology. 2016 June 6:112(3): 447-457. doi:10.1038/ajg.2016.500.

Addendum:

Effective 02/01/21: Anesthesia for bariatric procedures (00797) is covered without prior authorization (Internal).

Effective 05/01/21: Updated wording on the Bariatric Surgery Accreditation.

Resource Document:

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