| Coverage Policy Manual | |
| Policy #: | 2023001 |
| Category: | Surgery |
| Initiated: | January 2023 |
| Last Review: | January 2025 |
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| Bariatric Surgery for ASE/PSE Contracts | |
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| Description: |
Bariatric surgery is a treatment for morbid obesity in patients who fail to lose weight with conservative measures. There are numerous gastric and intestinal surgical techniques available. While these techniques have heterogeneous mechanisms of action, the result is a smaller gastric pouch that leads to restricted eating. However, these surgeries may lead to malabsorption of nutrients or eventually to metabolic changes.
Bariatric surgery is performed for the treatment of morbid (clinically severe) obesity. Morbid obesity is defined as a body mass index (BMI) greater than 40 kg/m2 or a BMI greater than 35 kg/m2 with associated complications including, but not limited to, type 2 diabetes, uncontrolled hypertension, cardiopulmonary conditions, severe obstructive sleep apnea, and other potentially life-threatening comorbid conditions (e.g. Pickwickian syndrome, pulmonary hypertension, etc) . Morbid obesity results in a very high risk for weight-related complications and a shortened life span. A morbidly obese man at age 20 can expect to live 13 years less than his counterpart with a normal BMI, which equates to a 22% reduction in life expectancy.
The first treatment of morbid obesity is dietary and lifestyle changes. Although this strategy may be effective in some patients, only a few morbidly obese individuals can reduce and control weight through diet and exercise. The majority of patients find it difficult to comply with these lifestyle modifications on a long-term basis.
When conservative measures fail, some patients may consider surgical approaches. A 1991 National Institutes of Health (NIH) Consensus Conference defined surgical candidates as those patients with a BMI* of greater than 40 kg/m2, or greater than 35 kg/m2 in conjunction with severe comorbidities such as cardiopulmonary complications or severe diabetes. (*See Policy Guidelines on how to calculate BMI.)
Resolution (cure) or improvement of type 2 diabetes mellitus after bariatric surgery and observations that glycemic control may improve immediately after surgery, before a significant amount of weight is lost, have promoted interest in a surgical approach to treatment of type 2 diabetes. The various surgical procedures have different effects, and gastrointestinal rearrangement seems to confer additional anti-diabetic benefits independent of weight loss and caloric restriction. The precise mechanisms are not clear, and multiple mechanisms may be involved. Gastrointestinal peptides, glucagon-like peptide-1 (1GLP-1), glucose -dependent insulinotropic peptide (GIP), and peptide YY (PYY) are secreted in response to contact with unabsorbed nutrients and by vagally mediated parasympathetic neural mechanisms. GLP-1 is secreted by the L cells of the distal ileum in response to ingested nutrients and acts on pancreatic islets to augment glucose-dependent insulin secretion. It also slows gastric emptying, which delays digestion, blunts postprandial glycemia, and acts on the central nervous system to induce satiety and decrease food intake. Other effects may improve insulin sensitivity. GIP acts on pancreatic beta cells to increase insulin secretion through the same mechanisms as GLP-1, although it is less potent. PYY is also secreted by the L cells of the distal intestine and increases satiety and delays gastric emptying.
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Policy/ Coverage: |
Note: Beginning January 1, 2023, for bariatric services for ASE/PSE members, please see the member’s Summary Plan Description (SPD). This policy applies only to those contracts subject to Arkansas Act 109 for State and Public School Health Insurance program
Prior Authorization is required for all procedures described as covered under the above Act.
Coverage will be limited to surgeries performed at bariatric surgery centers which are accredited through the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program as determined by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery. Bariatric Surgery coverage shall be limited to one bariatric surgery per lifetime and one revision surgery in the case of surgical complications resulting directly from the bariatric surgery. If an Active Employee or Retiree under the age of 65 has previously had bariatric surgery on a different health insurance plan, they shall not be eligible for the Bariatric Surgery Benefit
Effective January 1, 2023
Medical Necessity
Does Not Meet Medical Necessity Or Is Investigational
The following procedures do not meet member benefit certificate medical necessity that there be scientific evidence of effectiveness in improving health outcomes:
Policy Guidelines:
Patient Selection Criteria
Morbid obesity is defined as a body mass index (BMI) 40 kg/m2 or more or a BMI 35 kg/m2 or more with at least 1 clinically significant obesity-related disease such as diabetes, obstructive sleep apnea, coronary artery disease, or hypertension for which these complications or diseases are not controlled by best practice medical management.
While there are limited evidence on which to assess the long-term impacts of bariatric surgery for patients younger than age 18 years, severely obese (BMI ≥40 kg/m2 or 140% of the 95th percentile for age and sex, whichever is lower) adolescents with commonly present though not required comorbidities, or who have a BMI of 35 kg/m2 or greater (or 120% of the 95th percentile for age and sex, whichever is lower) with clinically significant disease may be considered for bariatric surgery according to the American Academy of Pediatrics (Armstrong et al, 2019). U.S. Food and Drug Administration (FDA) premarket approval for the LAP-BAND® System indicates it is intended for severely obese adults. (The clinical study submitted to FDA for approval of the LAP-BAND was restricted to adults ages 18-55 years.)
Patients 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.
Patients with a BMI of 50 kg/m2 or more need a bariatric procedure to achieve greater weight loss. Thus, the use of adjustable gastric banding, which results in less weight loss, should be most useful as a procedure for patients with a BMI less than 50 kg/m2. Malabsorptive procedures, although they produce more dramatic weight loss, potentially result in nutritional complications, and the risks and benefits of these procedures must be carefully weighed in light of the treatment goals for each patient.
Patients who undergo adjustable gastric banding and fail to achieve adequate weight loss must show evidence of postoperative compliance with diet and regular bariatric visits prior to consideration of a second bariatric procedure.
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| Rationale: |
This policy was developed in response to Arkansas Act 109 for State and Public School Health Insurance program.
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Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2025 American Medical Association. |
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