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Clinical Policy: Bariatric SurgeryReference Number: HNCA.CP.MP.37Last Review Date: 07/20Coding ImplicationsRevision LogSee Important Reminder at the end of this policy for important regulatory and legalinformation.DescriptionThere are two categories of bariatric surgery: restrictive procedures and malabsorptive procedures.Gastric restrictive procedures include procedures where a small pouch is created in the stomach torestrict the amount of food that can be eaten, resulting in weight loss. The laparoscopic adjustablegastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) are examples of restrictiveprocedures. Malabsorptive procedures bypass portions of the stomach and intestines causingincomplete digestion and absorption of food. Duodenal switch is an example of a malabsorptiveprocedure. Roux-en-y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch(BPD-DS), and biliopancreatic diversion with gastric reduction duodenal switch (BPD-GRDS) areexamples of restrictive and malabsorptive procedures.LAGB devices are currently not FDA approved for adolescents less than 18 years, and are beingused less for adolescents in favor of SG.Policy/CriteriaIt is the policy of Health Net of California that bariatric surgery is medically necessary when thefollowing criteria under section I and II are met:I. Medical history, meets all of the following:A. Age and body mass index (BMI) (meet criteria in 1 or 2)1. Age 18 and: Obesity has continued despite previous weight loss attempts, or waitingfor attempted weight loss could result in worsening of a health condition and one of thefollowing (a, b, or c):a. BMI 40 kg/m² and LABG, LSG, laparoscopic RYGB or laparoscopic BPDDS/BPD-GRDS is requested;b. BMI 35 and 40 kg/m² and both of the following:i. LAGB, LSG, laparoscopic RYGB or BPD-DS/BPD-GRDS is requested;ii. One of the following comorbidities is present:a) Type 2 diabetes mellitus (DM)h) Gastroesophageal reflux diseaseb) Poorly controlled hypertensioni) Asthmac) Dyslipidemiaj) Venous stasis diseased) Obstructive sleep apneak) Severe urinary incontinencee) Obesity-hypoventilationl) Osteoarthritis (hip, knees and/orsyndrome/Pickwickian syndromeankles)f) Nonalcoholic fatty liver diseasem) Idiopathic intracranialor nonalcoholic steatohepatitishypertensiong) Coronary artery diseasec. BMI 30 and 35 kg/m² and both of the following:i. Type 2 DM;ii. LAGB, LSG or laparoscopic RYGB is requested;Page 1 of 18

CLINICAL POLICYBariatric Surgery2. Age 18 years, LSG or laparoscopic RYGB is requested, and one of the following (aor b):a. BMI 40 kg/m² or 140% of the 95th percentile (whichever is lower);b. BMI 35 kg/m² or 120% of the 95th percentile with 1 severe comorbidity listedbelow that has significant short-term effects on health and that is uncontrolled withlifestyle or pharmacotherapy management:i. Type 2 DMvi. Slipped capital femoralii. Obstructive sleep apneaepiphysis (SCFE)iii. Idiopathic intracranialvii. Gastroesophageal refluxhypertensiondiseaseiv. Nonalcoholic steatohepatitisviii. Hypertensionv. Blount’s diseaseix. Hyperlipedemiax. Insulin resistanceII. Preoperative evaluation and medical clearance requirements within 6 months of thescheduled surgery include all of the following:A. Cardiac evaluation includes an electrocardiogram and one of the following categories (1or 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, itshould be conducted by a cardiologist.2. HIGH CARDIAC RISK candidates need consultation/evaluation and cardiacclearance from a cardiologist. High risk candidates include those with any of thefollowing: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. Glycemic control should be optimized as evidenced by one of the following (not requiredif qualifying for surgery based on BMI 30 kg/m2 and 35 kg/m2 with type 2 DM):1. HbA1c 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 macrovascularcomplications, extensive co-morbid conditions, or long-standing diabetes in whichthe general goal has been difficult to attain despite intensive efforts.C. Pulmonary Evaluation:1. Chest x-ray;2. Screening for obstructive sleep apnea;3. Pulmonary function testing and arterial blood gas analysis for candidates withintrinsic lung disease or disordered sleep patterns;Page 2 of 18

CLINICAL POLICYBariatric Surgery4. Polysomnography (PSG) for evaluation of obstructive sleep apnea in members whomeet at least one of the following criteria for PSG:a. Recurrent witnessed apnea during sleep 10 seconds in duration;b. Excessive or inappropriate daytime sleepiness such as falling asleep while drivingor eating;c. Sleepiness that interferes with daily activities not explained by other conditions,such as poor sleep hygiene, medication, drugs, alcohol, psychiatric orpsychological disorders;d. Having an Epworth Sleepiness Scale score 10;e. Persistent or frequent disruptive snoring, choking or gasping episodes associatedwith awakenings;5. Specialist should be consulted for interpretation of any abnormal findings.D. Nutritional evaluation, including micronutrient measurements and treatment ofinsufficiencies/deficiencies prior to surgery.E. Nutritional therapy/counseling1. Initial comprehensive diet history to include assessment of current pattern of nutritionand 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 thepotential for success of weight loss surgery dependent on post-op diet modification (ifpatient 18 years of age, consultation must be with adolescent ANDparent/guardian).F. Age appropriate psychiatry/psychology consultation including all of the following:1. An in-person psychological evaluation to assess for major mental health disorderswhich would contradict surgery and determine ability to comply with post-operativecare and guidelines;2. If history is positive for alcohol or drug abuse, meets both of the following:a. Must provide documentation of alcohol and drug abstinence for 1 year prior tosurgery;3. If age 18 years: evaluation must also include assessment of emotional maturity,decisional capacity, family support and family willingness to participate in lifestylechanges.G. Members with signs or symptoms of hypothyroidism (other than obesity) are screenedwith a TSH level and treated if found to be hypothyroid.H. A fasting lipid panel must be obtained and treatment initiated for dyslipidemia.I. Screening for Helicobacter pylori if signs or symptoms of active peptic ulcer disease arepresent, with documentation of treatment if positive for H.pylori.J. Prophylactic treatment for gouty attacks in patients with a history of gout.Page 3 of 18

CLINICAL POLICYBariatric SurgeryK. If tobacco user, must stop use 6 weeks prior to surgery.III. Repeat SurgeriesA. Repeat bariatric surgery is considered medically necessary for one of the following:1. To correct complications from a previous bariatric surgery, such as obstruction orstrictures (could include conversion surgeries to LSG or RYGB for adults oradolescents; or BPD-DS for adults);2. Conversion from LAGB to a LSG, RYGB or BPD-DS; or revision of a primaryprocedure that has failed due to dilation of the gastric pouch when all of the followingcriteria 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 2 years prior to repeat procedure;c. Weight loss from the initial procedure was less than 50% of the member's excessbody weight at the time of the initial procedure;d. If the conversion is requested due to removal of an eroded laparoscopic adjustableband, at least two months have passed between the band removal and thesubsequent bariatric procedure;e. Documented compliance with previously prescribed postoperative nutrition andexercise program. If non-compliant with postoperative regimen, member will berequired to take part in an established multidisciplinary bariatric program to meetall of the initial surgery criteria listed above;f. Supporting documentation from the provider should also include a clinicalexplanation of the circumstances as to why the procedure failed and if initialprocedure failure was related to non-compliance with diet then why the requestingprovider feels member will be compliant with diet after repeat surgery.3. Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass for the treatment ofgastro-esophageal reflux disease (GERD) when anti-reflux medical therapy has beentried and failed.IV. Contraindications for surgical weight loss procedures include:A. Medically correctable causes of obesity;B. Current or planned pregnancy within 12 to 18 months of the procedure;C. Severe coagulopathy.V. It is the policy of Health Net of California that the following bariatric surgery procedures areconsidered investigational, because the medical literature indicates that studies have beeninadequate to determine their efficacy and long-term outcomes:A. Distal gastric bypass (very long limb gastric bypass);B. Loop Gastric Bypass ("Mini-Gastric Bypass");C. Laparoscopic re-sleeve gastrectomy (LRSG) performed after the resulting gastric pouchis primarily too large or dilates after the original LSG;D. Fobi pouch;E. Laparoscopic greater curvature plication (Gastric Imbrication);F. LAP-BAND when BMI is 30 to 35 with or without comorbid conditions;G. AspireAssist;Page 4 of 18

CLINICAL POLICYBariatric SurgeryH.I.J.K.Endoscopic Suture Revisions post bariatric surgery;Single anastomosis duodenoileal bypass (SADI);Gastric plication/ Endoluminal vertical gastroplasty;Endoscopic gastrointestinal bypass devices (EGIBD (barrier devices);VI. It is the policy of Health Net of California that the following bariatric surgery procedures areconsidered not medically necessary, due to potential complications and a lack of positiveoutcomes: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.BackgroundThere is sufficient evidence in peer-reviewed medical literature to support the use of the abovementioned bariatric surgeries for the clinically obese individual. Persons with clinically severeobesity are at risk for increased mortality and multiple co-morbidities. These co-morbiditiesinclude hypertension, hypertrophic cardiomyopathy, hyperlipidemia, diabetes, cholelithiasis,obstructive sleep apnea, hypoventilation, degenerative arthritis and psychosocial impairments.The majority of severely obese patients losing weight through non-operative methods aloneregain all the weight lost over the next five years. Surgical treatment is the only proven methodof achieving long term weight control for the morbidly obese. Eating behaviors after surgeryimprove dramatically due to the restricted size of the stomach allowing only small amounts offood to be taken in at a time.The success of the bariatric surgery does rely on the motivation and dedication to the program ofthe patient. The patient must be able to participate in the treatment and long-term follow uprequired after surgery. Studies have shown that about 10% of patients may have unsatisfactoryweight loss or regain much of the weight they have lost. This may occur due to frequentsnacking on high-calorie foods or lack of exercise. Technical problems that may occur include astretched pouch due to overeating following surgery. Ensuring patients are motivated to loseweight can help prevent some of these issues.Maximum weight loss usually occurs between 18 and 24 months postoperatively. The averageweight loss at five years ranges from 48 to 74% after gastric bypass and 50 to 60% followinggastric banding. Several studies have follow-up from 5-15 years with these patients maintainingweight loss of 50-60% of excess weight. The Lap Band is a small bracelet-like band placedaround the top of the stomach to produce a small pouch about the size of a thumb. The size ofthe outlet is controlled by a circular balloon inside the band that can be inflated and deflated withsaline solution through an access port placed under the skin. The more inflated the balloon, thenarrower the opening and slower passage of food to the rest of the stomach.Page 5 of 18

CLINICAL POLICYBariatric SurgeryRoux-en-Y gastric bypass (RYGB) creates a small stomach pouch, bypassing most of thestomach, duodenum, and upper intestine. Weight loss occurs through restriction of food intakeand by decreasing the absorption of food by re-routing food directly from the pouch into thesmall intestine.Biliopancreatic diversion with duodenal switch (BPD-DS) is a complex operation that includes1) removing a large portion of the stomach to promote smaller meal sizes, 2) re-routing of foodaway from much of the small intestine to prevent partial absorption of food, and 3) re-routing ofbile and other digestive juices that impair digestion. The operation bypasses most of theduodenum, but leaves a small portion for food and the absorption of some vitamins and minerals.BPD-DS produces significant weight loss, but has a greater risk of long-term complications dueto decreased absorption of food, vitamins, and minerals.There are both early and later complications associated with these operations. Earlycomplications can include bleeding, infections, leaks from suture sites and blood clots.Strictures, hernias, and malnutrition, especially when not taking prescribed vitamins andminerals, are all late complications that can occur in addition to the above mentioned stretchedpouch or separated stitches. A repeat surgery is at times required to repair some of thesecomplications.In an updated position statement on the role of bariatric surgery in class I obesity (BMI of 30.0–34.9 kg/m 2), the American Society for Metabolic and Bariatric Surgery (ASMBS) recommendpatients with BMI 30 to 35 kg/m 2 and obesity- related co-morbidities who do not achievesubstantial, durable weight loss and co-morbidity improvement with reasonable nonsurgicalmethods, bariatric surgery should be offered as an option for suitable individuals. In thispopulation, surgical intervention should be considered after failure of nonsurgical treatments.Particularly given the presence of high-quality data in patients with type 2 diabetes, bariatric andmetabolic surgery should be strongly considered for patients with BMI 30 to 35 kg/m 2 and type2 diabetes. AGB, SG, and RYGB have been shown to be well- tolerated and effective treatmentsfor patients with BMI 30 to 35 kg/m 2. Safety and efficacy of these procedures in low-BMIpatients appear to be similar to results in patients with severe obesity. Currently, the bestevidence for bariatric and metabolic surgery for patients with class I obesity and co-morbidconditions exists for patients in the 18 to 65 age group.33Bariatric Surgery in AdolescentsWeight loss surgery has been performed in small groups of adolescents since the 1970s. Recentdata has shown a significant increase in the rate since 2000. It is likely that we will continue tosee a rise in the rate of adolescents undergoing weight loss surgery with the current pediatricobesity epidemic. Children and adolescents who are severely obese are at risk for the samemortality and co-morbidities as adults. These co-morbidities include hypertension, hypertrophiccardiomyopathy, hyperlipidemia, diabetes, cholelithiasis, obstructive sleep apnea, depression andimpaired quality of life. In addition, children in the BMI category 35 kg/m2 will almost alwaysremain obese and 65% will have a BMI 40 as an adult.Changes in diet and physical activity must be attempted prior to weight loss surgery inadolescents. A multi-disciplinary, family-based approach should be undertaken to support aPage 6 of 18

CLINICAL POLICYBariatric Surgerystaged weight loss plan. However, studies suggest that dietary and behavioral interventionsrarely result in significant and sustained weight loss in adolescents. This same multi-disciplinaryand family approach must be taken when evaluating and planning for bariatric surgery in anadolescent.The multi-disciplinary team should include an experienced bariatric surgeon, pediatric obesityspecialist, nurse, dietician, and pediatric psychologist or psychiatrist. Additional sub-specialistsmust be readily available for evaluation of co-morbidities. The success of the bariatric surgerydoes rely on the motivation and dedication to the program of the patient and their family. Thepatient and family must be willing and able to participate in the treatment and long-term followup required after surgery. The adolescent must show evidence of mature decision-making withappropriate understanding of the risks and benefits of surgery.Current existing retrospective data on adolescent weight loss surgery demonstrate that bypassleads to clinically significant and durable decrease in weight loss and BMI. Studies haveinvestigated LABG for the treatment of adolescent obesity, but it has fallen out of favor due tomodest weight loss and high rates of revision and weight recidivism. Obesity-related diseasesalso improve or resolve after surgically induced weight loss in adolescents. There have not beenenough studies to indicate what the long-term weight loss sustainability is in adolescents.Specific predictors of weight regain after bariatric surgery are still unknown.Recently updated guidelines from the ASMBS on pediatric metabolic and bariatric surgeryconclude that metabolic and bariatric surgery (MBS) is a proven, effective treatment for severeobesity disease in adolescents and should be considered standard of care. Treatment of severeobesity in adolescents clearly requires a multidisciplinary approach where MBS should not beconsigned to the treatment of last resort. Rather, when considered appropriate and within theclinical best practice guidelines, MBS should be readily offered to adolescents with obesity toeffectively reverse co-morbidities and achieve overall wellness. Prior weight loss attempts,Tanner stage, and bone age should not be barriers to definitive treatment. 34Investigational ProceduresLong-limb or Distal Gastric Bypass for Superobesity: An RCT has recently been completed bySvanevik et al., but only perioperative outcomes have been reported thus far. Svanevik et al.found that in superobese patients with BMI between 50 and 60 kg/m(2), distal gastric bypass wasassociated with longer operating time and more severe complications resulting in reoperationthan proximal gastric bypass. There is increased risk of adverse nutritional outcomes with longerlimb gastric bypass. At this time the long-limb or distal gastric bypass for superobesity isconsidered investigational, until more long-term studies can be done which reflect betteroutcomes than existing procedures.Loop Gastric Bypass (Mini Gastric Bypass, one-anastomosis gastric bypass): The mini gastricbypass has not been universally accepted due to higher rates of alkaline bile reflux and limitedlong-term research. More long-term research is needed to solidify mini gastric bypass surgery’sposition as a viable bariatric surgery option.Page 7 of 18

CLINICAL POLICYBariatric SurgeryRe-Sleeve Gastrectomy for Failed Laparoscopic Sleeve Gastrectomy: Iannelli et al. (2012) notedthat laparoscopic sleeve gastrectomy (LSG) was rapidly accepted as a valuable bariatricprocedure before its effectiveness on weight loss in the long-term is clearly demonstrated. Theauthors report a feasibility study including 13 patients undergoing a redo LSG for eitherprogressive weight regain after initial weight loss of insufficient weight loss. AlSabah et al.describe 24 patients who underwent re-sleeve laparoscopic gastrectomy after an initial LSG.Compared to 12 patients that initially had LSG, which was converted to LRYGB, results weresimilar, with no significant differences in percent of excess weight loss at one year. Theyconclude that larger and longer follow-up studies are needed to verify results.Fobi Pouch or Silastic Ring: The Fobi Pouch bariatric operation for obesity is a combination ofstomach reduction and gastric bypass. The Silastic ring is placed around the verticallyconstructed gastric pouch above the anastomosis between the pouch and the intestinal Rouxlimb. Possible long term nutritional deficiencies involve fat soluble vitamin deficiencies ofCalcium, Iron, B12, and Folic Acid. Patients are placed on nutritional supplements for the rest oftheir lives, and yearly monitoring is needed. The Fobi Pouch gastric bypass takes about doublethe time that a vertical banded gastroplasty operation takes. There is limited research on theoutcomes of the Fobi pouch versus other bariatric surgery procedures.Gastric Imbrication: Fried et al. (2011) completed a 3-year RCT on the safety and efficacy oflaparoscopic adjustable gastric banding with and without imbrication sutures. The results of theRCT have demonstrated that SAGB combined with a conservative approach to band adjustmentsand limited retrogastric dissection is effective and safe with and without imbrication sutures. Notusing imbrication sutures results in significant benefits in operative speed with comparableclinical weight loss and intermediate term safety. Sharma et al. conducted a randomized, doubleblinded trial comparing LSG and laparoscopic gastric imbrication (LGI). They found nodifferences in weight, age, or BMI preoperatively at 6 months or 3 years between the 2 groups.The AspireAssist System (AspireAssist) was FDA approved in 2016. It is a weight loss devicecomprised of an endoscopically placed percutaneous gastrostomy tube and an external device tofacilitate drainage of about 30% of each meal consumed. It is meant to be used in conjunctionwith diet and exercise. Thompson et al. (2017) performed a 1-year RCT comparing results of 207patients treated with AspireAssist. The treatment group (n 137) received AspireAssist andlifestyle counseling and the control group (n 70) received lifestyle counseling alone. Comparedto the control group, those who received the AspireAssist and counseling lost more weight:58.6% of participants in the AspireAssist group and 15.3% of participants in the LifestyleCounseling group lost at least 25% of their excess body weight (P 0.001). Additionally, Norenet al. (2016) conducted a prospective observational study on 25 patients. By the end of the 2-yearobservation period only 15 patients were still in the study. They concluded that AspireAssist isan efficient and safe treatment for obesity. There is no research on AspireAssist versus otherbariatric surgery procedures.To enhance weight loss, the following endoscopic procedures have been attempted to promoterestriction of the pouch or stoma. These revisions have included: sclerotherapy of the site using 6to 30 mL of sodium morrhuate injected circumferentially; tissue plication systems to reduce thesize of the gastrojejunostomy and the gastric pouch; revisional surgery using a tissue plicationPage 8 of 18

CLINICAL POLICYBariatric Surgerydevice known as StomaPhyX to reduce the pouch size; and application of the endoclip to reducethe size of the gastrojejunal anastomosis. There is a lack of long-term outcomes for endoscopicrevisions post RYGB.The single anastomosis duodenoileal bypass (SADI), also known as single-anastomosis duodenalswitch (SADS) combines restrictive, malabsorptive, and probably hormonal mechanisms forweight loss. The sleeve is created first, and the duodenum is divided after the pylorus. SADIcreates an anastomosis between the side of the distal ileum and the end of the sleeve-like gastricpouch/duodenum. Data evaluating this procedure is limited. Technical complexity and longterm nutritional deficiencies have limited its acceptance. 16Endoluminal vertical gastroplasty/gastric plication is an endoscopic approach for suturing thestomach that offers the potential to perform gastric-restrictive procedures endoluminally. Theanterior and posterior walls of the stomach are suctioned together, then held in place by either astapler or T-fastener device to create a tube of stomach similar to the sleeve gastrectomy.Endoscopic gastrointestinal bypass devices (EGIBD) are barrier devices deployed to preventluminal contents from being absorbed in the proximal small intestine (e.g., ValenTX,EndoBarrier). Data are still lacking about the longevity of these endobarriers and their outcomesonce the barrier is removed.Not Medically Necessary ProceduresBiliopancreatic Diversion (BPD) Procedure (Scopinaro procedure): The biliopancreatic diversion(BPD) is a malabsorptive procedure that was introduced as a solution to the high rates of liverfailure resulting from bowel exclusion in the jejunoileal bypass. The procedure consists of apartial gastrectomy and gastroileostomy with a long segment of Roux limb and a short commonchannel, resulting in fat and starch malabsorption. BPD also has a restrictive component. TheBPD/DS procedure differs from the BPD in the portion of the stomach that is removed, as wellas preservation of the pylorus. This allows more forward flow of the contents of thebiliopancreatic limb and avoids the complications of stasis that plagued the jejunoileal bypass(JIB). It is associated with fewer complications than BPD alone. BPD/DS is a complex procedurethat is only performed at a few centers in the U.S.Jejunoileal Bypass or Jejunoileal Intestinal Bypass (JIB): The jejunoileal bypass (also called theintestinal bypass) is performed by dividing the jejunum close to the ligament of Treitz andconnecting it a short distance proximal to the ileocecal valve, thereby diverting a long segment ofsmall bowel, resulting in malabsorption. This procedure is no longer performed due to the highcomplication rate and frequent need for revisional surgery. Per the American Society forMetabolic & Bariatric Surgery, the JIB is no longer a recommended bariatric surgical procedure.The lessons learned from the JIB include the crucial importance of long-term follow-up and thedangers of a permanent, severe and global malabsorption.Vertical Banded Gastroplasty (VBG): VBG has fallen out of favor as a restrictive procedure forsevere obesity, due largely to the advantages of adjustable gastric banding. VBG requiresdivision of the stomach or intestinal resection, while LAGB does not. In addition, the staplesused in VBG may break down and cause weight regain, and VBG requires the use of prostheticPage 9 of 18

CLINICAL POLICYBariatric Surgerymesh that may increase the incidence of stomach stenosis. Thus, CMS says in their NationalCoverage Determination for Bariatric Treatment for Morbid Obesity that “VBG procedures areessentially no longer performed.”Gastric Balloon: Previous endoscopic technologies used to treat obesity endoscopically, such asthe gastric balloon, had limited exposure in the U.S. and were removed from the market becauseof associated complications, such as balloon deflation with migration and resultant smallintestinal obstruction.Gastric Pacing: A number of procedures have been investigated for weight loss surgery but havenot been totally accepted by the surgical community. Gastric pacing has been performed inseveral trials but has not been shown to have any long-term effect and has been abandoned.Gastric Wrapping: A gastric wrap is minimally invasive surgery and involves folding thestomach in on itself and then the edges are stitched to turn the stomach into a narrow tubetherefore restricting the amount of food that can be consumed. As this surgery is very new andnot widely offered. There is a paucity of peer-reviewed scientific literature on this procedure.Coding ImplicationsThis clinical policy references Current Procedural Terminology (CPT ). CPT is a registeredtrademark of the American Medical Association. All CPT codes and descriptions are copyrighted2020, American Medical Association. All rights reserved. CPT codes and CPT descriptions arefrom the current manuals and those included herein are not intended to be all-inclusive and areincluded for informational purposes only. Codes referenced in this clinical policy are forinformational purposes only. Inclusion or exclusion of any codes does not guarantee coverage.Providers should reference the most up-to-date sources of professional coding guidance prior tothe submission of claims for reimbursement of covered services.CPT codes that support medical necessityCPT * DescriptionCodes43644Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass andRoux-en-Y gastroenterostomy (roux limb 150 cm or less)43645Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass andsmall intestine reconstruction to limit absorption43770* Laparoscopy, surgical, gastric restrictive procedure; placement of adjustablegastric restrictive device (eg, gastric band and subcutaneous port components)43771Laparoscopy, surgical, gastric restrictive procedure; revision of adjustablegastric restrictive device component only43772Laparoscopy, surgical, gastric restrictive procedure; removal of adjustablegastric restrictive device component only43773Laparoscopy, surgical, gastric restrictive procedure; removal and replacementof adjustable gastric restrictive device component only43774Laparoscopy, surgical, gastric restrictive procedure; removal of adjustablegastric restrictive device and subcutaneous port componentsPage 10 of 18

CLINICAL POLICYBariatric Surger

Bariatric Surgery Page 4 of 18 K. If tobacco user, must stop use 6 weeks prior to surgery. III.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