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Surgical reversal (i.e., takedown), revision of a previous bariatric surgical procedure or conversion toanother bariatric surgical procedure is considered not medically necessary for EITHER of the following: Inadequate weight loss due to individual noncompliance with postoperative nutrition andexercise recommendationsANY other indicationAdolescentsBariatric surgery for the treatment of morbid obesity in an adolescent (age 11–17 years) is consideredmedically necessary using a covered procedure outlined below when ALL of the following criteria aremet: The individual has evidence of EITHER of the following: BMI (Body Mass Index) 40 kg/m2 BMI (Body Mass Index) 35–39.9 kg/m2 with at least one clinically significant obesity-relatedcomorbidity, including but not limited to the following:ooooooo coronary artery diseasediabetes mellitusidiopathic intracranial hypertensionpoorly controlled hypertension (systolic blood pressure at least 140 mm Hg or diastolic bloodpressure 90 mm Hg or greater, despite optimal medical management)obstructive sleep apneagastroesophageal refluxnonalcoholic steatohepatitis [NASH])A thorough multidisciplinary evaluation within the previous 12 months which includes ALL of thefollowing: a description of the proposed procedure(s)documentation of failure of weight loss by medical managementunequivocal clearance for bariatric surgery by a mental health providera nutritional evaluation by a physician, physician assistant, nurse practitioner or registered dieticianBariatric Surgery Procedures (Adolescents)When the specific medical necessity criteria noted above for bariatric surgery for an adolescent havebeen met, ANY of the following open or laparoscopic bariatric surgery procedures for the treatment ofmorbid obesity is considered medically necessary:ProcedureSleeve gastrectomyRoux-en-Y gastric bypass(roux limb less than 150 CM)Roux-en-Y gastric bypass(roux limb greater than 150 CM)Open CPT Codes4384343846Laparoscopic CPT Codes43775436444384743645All other bariatric surgery procedures for the treatment of morbid obesity in an adolescent areconsidered experimental, investigational or unproven.Reoperation and Revisional Bariatric Surgery (Adolescents)Page 5 of 90Medical Coverage Policy: 0051

The following procedures are considered medically necessary when the adolescent develops a majorcomplication from a primary bariatric surgery procedure (e.g., stricture, obstruction, erosion, gastricprolapse, ulceration, fistula formation, esophageal dilatation, gastroesophageal reflux disease refractoryto medical therapy): surgical repairconversion to a medically necessary bariatric surgery procedure (i.e., Roux-en-Y or sleeve gastrectomy)Revision of a previous bariatric surgical procedure or conversion to another procedure for anadolescent is considered medically necessary when BOTH of the following are met: Individual has not obtained adequate weight loss**NOTE: inadequate weight loss is defined as failure to lose at least 50% of excess body weightor failure to achieve body weight to within 30% of ideal body weight at least two years followingthe original surgery.The requested procedure includes ANY of the following:ProcedureSleeve gastrectomyRoux-en-Y gastric bypass(roux limb less than 150 CM)Roux-en-Y gastric bypass(roux limb greater than 150 CM)Revision of gastrojejunal anastomosis(gastrojejunostomy)Open CPT Codes4384343846Laparoscopic CPT Codes437754364443847436454386043659Individuals with weight loss failure two years following a primary bariatric surgery procedure mustmeet the initial medical necessity criteria for surgery.Surgical reversal (i.e., takedown), revision of a previous bariatric surgical procedure or conversion toanother bariatric surgical procedure is considered not medically necessary for EITHER of the following: Inadequate weight loss due to individual noncompliance with postoperative nutrition andexercise recommendationsANY other indicationAdults and AdolescentsBariatric Surgery for the Treatment of Other ConditionsBariatric surgery is considered experimental, investigational or unproven for the primary treatment ofany condition other than morbid obesity.Cholecystectomy, Liver Biopsy, Herniorrhaphy, Prophylactic Vena Cava Filter Placement, or UpperEndoscopyProphylactic vena cava filter placement at the time of bariatric surgery is considered medicallynecessary for an individual who is considered to be high risk for venous thromboembolism (VTE) due toa history of ANY of the following conditions: deep vein thrombosis (DVT)hypercoagulable stateincreased right-sided heart pressurespulmonary embolus (PE)Page 6 of 90Medical Coverage Policy: 0051

The following procedures performed in conjunction with a bariatric surgery are considered not medicallynecessary: cholecystectomy in the absence of signs or symptoms of gallbladder diseaseliver biopsy in the absence of signs or symptoms of liver disease (e.g., elevated liver enzymes,enlarged liver, abnormal intraoperative findings)routine vena cava filter placement for individuals not at high risk for venous thromboembolism (VTE)When performed concurrently as part of a bariatric surgery procedure EACH of the following isconsidered integral to the procedure and not separately reimbursable: simple suture repair (i.e., without mesh) of a diaphragmatic defect for a hiatal hernia upper gastrointestinal endoscopy performed concurrent with a bariatric surgery procedure toconfirm a surgical anastomosis or to establish anatomical landmarksGeneral BackgroundObesity and overweight are defined clinically using the body mass index (BMI). BMI is an objective measurementand is currently considered the most reproducible measurement of total body fat. In adults, excess body weight(EBW) is defined as the amount of weight that is in excess of the ideal body weight (IBW), or a BMI 25 kg/m2The National Heart, Lung and Blood Institute (NHLBI) (1998) clinical guidelines recommended that the BMIshould be used to classify overweight and obesity and to estimate relative risk for disease compared to normalweight The NHLBI (1998) defined the following classifications based on BMI:ClassificationBMIUnderweight 18.5 kg/m2Normal weight18.5–24.9 kg/m2Overweight25.0–29.9 kg/m2Obesity (Class 1)30.0–34.9 kg/m2Obesity (Class 2)35.0–39.9 kg/m2Extreme Obesity (Class 3) 40 kg/m2BMI is a direct calculation based on height and weight, regardless of gender:BMI weight (kg )height (m 2 ) weight (lb) x 7032 height (in) OR Clinically severe or morbid obesity is defined as a BMI 40 kg/m2 or a BMI of 35–39.9 kg/m2 with comorbidconditions. Another group of individuals who have been identified are the super-obese. Super-obesity has beendefined in the literature as a BMI 50 kg/m2. Comorbidities of morbid obesity that may be considered includeany of the following: mechanical arthropathy (weight-related degenerative joint disease)type 2 diabetesclinically unmanageable hypertension (systolic blood pressure at least 140 mm Hg or diastolic bloodpressure 90 mm Hg or greater, or if individual is taking antihypertensive agents)hyperlipidemiacoronary artery diseaselower extremity lymphatic or venous obstructionPage 7 of 90Medical Coverage Policy: 0051

severe obstructive sleep apneaobesity-related pulmonary hypertensionOther severe obesity-related co-morbidities including obesity-hypoventilation syndrome (OHS), Pickwickiansyndrome (a combination of obstructive sleep apnea [OSA] and OHS), nonalcoholic fatty liver disease (NAFLD)or nonalcoholic steatohepatitis (NASH), pseudotumor cerebri, gastroesophageal reflux disease (GERD), asthma,venous stasis disease, severe urinary incontinence, or considerably impaired quality of life, may also beconsidered for bariatric surgical intervention (Mechanick, et al., 2013, updated 2020).Epidemiologic data has shown that lower BMI values are correlated with risk of type 2 diabetes, cardiometabolicrisk factors and increased risk of mortality in South Asian, Southeast Asian, and East Asian populations whencompared to other ethnic groups (Ntuk, et al., 2014; Razak et al., 2007; Zhou, 2002). In 2000, the World HealthOrganization proposed the following weight classification in adult Asians: BMI 18.5 kg/m2 indicatesunderweight, 18.5 to 22.9 kg/m2 healthy weight, 23 to 24.9 kg/m2 overweight, 25 to 29.9 kg/m2 obese class I, and 30 kg/m2 obese class II. The U.S. Census Bureau collects race data according to U.S. Office of Managementand Budget guidelines, and these data are based on self-identification. According to the U.S. Census Bureau, anAsian is a person with origins from the Far East (China, Japan, Korea, and Mongolia), Southeast Asia(Cambodia, Malaysia, the Philippine Islands, Thailand, Vietnam, Indonesia, Singapore, Laos, etc.), or the Indiansubcontinent (India, Pakistan, Bangladesh, Bhutan, Sri Lanka, and Nepal) (2010). The National Center for HealthStatistics, a division of the Centers for Disease Control (CDC), also collects data on race and states that race isbased on a respondent's description of their own racial background, regardless of Hispanic or Latino origin(2019).The U.S. Department of Health and Human Services set goals for the nation with Healthy People 2020.Healthy People 2020 states, “Obesity is a problem throughout the population. However, among adults, theprevalence is highest for middle-aged people and for non-Hispanic black and Mexican American women(Flegal, et al., 2010). Among children and adolescents, the prevalence of obesity is highest among olderand Mexican American children and non-Hispanic black girls (Ogden, et al., 2010). The association ofincome with obesity varies by age, gender, and race/ethnicity (Ogden, et al., 2007).” According to theNational Health and Nutrition Examination Survey 2013-2016 data, more women (40.8%) than men (36.5%)were obese, with non-Hispanic black women having the highest prevalence (55.9%) (Hales , et al., 2018).Health disparities have been identified in outcomes of bariatric surgery among ethnic groups. Sheka et al. (2019)reported on an analysis of 108,198 patients from the 2015 Metabolic and Bariatric Surgery Accreditation andQuality Improvement Program national database to identify differences in mortality, length of stay, readmission,and reintervention by race in patients undergoing laparoscopic Roux-en-Y gastric bypass or laparoscopic sleevegastrectomy (SG). Black patients had a higher body mass index (BMI) preoperatively (laparoscopic Roux-en-Ygastric bypass: 48.0 kg/m2 vs. 45.7 kg/m2; SG 46.8 kg/m2 vs. 44.9 kg/m2). In both the laparoscopic Roux-en-Ygastric bypass and SG groups, black patients had significantly longer length of stay and higher rates ofreadmission. Black patients had significantly higher 30-day mortality (0.2% versus 0.1%, p .001) and higherrates of reoperation or reinterventions in the SG group. Amirian et al. (2020) compared the 30-day postoperativeoutcomes of 106,932 patients from the 2016 Metabolic and Bariatric Surgery Accreditation and QualityImprovement Program (MBSAQIP) database who underwent primary laparoscopic Roux-en-Y gastric bypass(LRYGB) or laparoscopic sleeve gastrectomy (LSG). The majority of the patients were white (79.5%), followedby 19.3% African American (AA), 0.5% Asian, 0.4% American Indian or Alaska Native, 0.3% Native Hawaiian orother Pacific Islander. After controlling for other covariates in multivariate logistic regression and selecting whitesas reference, AA was the only race associated with a higher risk of postoperative complications andreadmissions. Additionally, AA and American Indian or Alaska Natives were associated with a higherreintervention rate. For postoperative complications, AA had higher rates of pulmonary embolism and longerlength of stay; Asian patients had higher wound disruption, urinary tract infections, and myocardial infarction.Mocanu et al. (2020) conducted a retrospective review of the Metabolic and Bariatric Surgery Accreditation andQuality Improvement Program data registry (MBSAQIP) patients who underwent primary laparoscopic sleevegastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB) from 2015 to 2017 to identify rates of postoperativecomplications based on specific patient populations. A total of 430,936 patients were identified with 79.3%Page 8 of 90Medical Coverage Policy: 0051

female, 73.1% white, 17.6% African-American and 9.3% other. When compared to females, males were morelikely to develop complications (3.7% versus 3.45%; p 0.002), had increased reoperation rates (1.33% vs.1.18%; p 0.001) and a 2-fold greater mortality (0.18% vs. 0.07; p 0.001). At 30 days, female patients hadincreased intervention rates (1.34% vs. 1.18%; p 0.001) and readmission rates (3.89% vs. 3.53%; p 0.001).Black patients had higher rates of serious complications (4.14% vs. 3.41%; p 0.001), mortality (0.13% vs.0.09%; p 0.001), intervention (1.74% vs. 1.24%; p 0.001), and readmission (5.03% vs. 3.56%; p 0.001) at 30days when compared with white patients. Independent predictors of major complications were female sex(p 0.001) and black race (p 0.001). Black race was one of the greatest independent predictors of mortality(p 0.001). As identified in these studies, there are significant differences in outcomes following bariatric surgery.The factors that underlie these disparities are unclear and requires further study to optimize bariatric surgeryoutcomes.Strategies for Weight LossTreatment of obesity is generally described as a two-part process: 1) assessment, including BMI measurementand risk factor identification; and 2) treatment/management. Obesity management includes primary weight loss,prevention of weight regain and the management of associated risk. During the assessment phase, the individualneeds to be prepared for the comprehensive nature of the program, including realistic timelines and goals.General recommendations for an overall weight-loss strategy include the following (Gorroll and Mulley, 2009): For overweight or obese patients not ready to lose weight, the best approach is to educate them abouthealth risks, address other cardiovascular risk factors, and encourage the maintenance of their currentweight.For motivated persons who are overweight (BMI 25 to 29.9 kg/m2) and have two or more obesity-relatedmedical conditions or are frankly obese (BMI 30 kg/m2), a six-month goal of a 10% weight loss can beset (1 to 2 lb/week) and a program of diet, exercise, and behavioral therapy prescribed. If, after sixmonths, the target weight is not achieved, one can consider adding pharmacologic therapy for those atgreatest risk (BMI 27 kg/m2 plus two or more cardiovascular risk factors, or BMI 30 kg/m2).For markedly obese persons at greatest risk (BMI 35 kg/m2 with two or more obesity-related medicalconditions or BMI 40 kg/m2), consider a surgical approach if serious and repeated attempts using theforegoing measures have been unsuccessful.The NHLBI guidelines (1998) include the following recommendations regarding nonsurgical strategies forachieving weight loss and weight maintenance: Dietary Therapy: Increased Physical Activity/Exercise is recommended as part of a comprehensive, weight-loss therapyand weight-maintenance program because it: Low-calorie diets are recommended for weight loss in overweight and obese persons. Reducing fatas part of a low-calorie diet is a practical way to reduce calories.Optimally, dietary therapy should last at least six months, as many studies suggest that the rate ofweight loss decreases after about six months. Shorter periods of dietary therapy typically result inlesser weight reductions.The literature suggests that weight-loss and weight-maintenance therapies that provide a greaterfrequency of contacts between the individual and the practitioner and are provided over the longterm should be put in place. This can lead to more successful weight loss and weight maintenance.modestly contributes to weight loss in overweight and obese adultsmay decrease abdominal fatincreases cardiorespiratory fitnessmay help with maintenance of weight lossCombined Therapy: The combination of a reduced-calorie diet and increased physical activity isrecommended, since it produces weight loss, decreases abdominal fat and increases cardiorespiratoryfitness.Page 9 of 90Medical Coverage Policy: 0051

Behavior Therapy: Is a useful adjunct when incorporated into treatment for weight loss and weightmaintenance.In addition, the NHLBI recommended that weight-loss drugs approved by the U.S. Food and Drug Administration(FDA) only be used as part of a comprehensive weight-loss program, including diet and physical activity forindividuals with a BMI 30 with no concomitant obesity-related risk factors or diseases, or for individuals with aBMI 27 with concomitant obesity-related risk factors or diseases.Clinical supervision is an essential component of dietary management. According to the NHLBI (1998), “frequentclinical encounters during the initial six months of weight reduction appear to facilitate reaching the goals oftherapy”. Nutritional counseling by a registered dietitian (RD) in the course of treatment for patients with eatingdisorders, including overweight and obesity is optimal, as the RD is uniquely qualified to provide medical nutritiontherapy for the normalization of eating patterns and nutritional status (American Dietetic Association, 2006).Lifestyle modification should include a referral to a registered dietitian or credible weight loss program/service forcounseling in energy intake reduction and nutritional strategies with a weight reduction goal of 5 10% of totalbody weight. During the period of active weight loss, regular visits of at least once per month and preferablymore often with a health professional for the purposes of reinforcement, encouragement, and monitoring willfacilitate weight reduction (NHLBI, 1998). Physicians can also provide clinical oversight and monitoring of whatare often complex comorbid conditions and can select the optimal and most medically appropriate weightmanagement, nutritional and exercise strategies. Some commercially available diet programs do not consistentlyprovide counselors who are trained and certified as registered dieticians or with other equivalent clinical training.However, diet programs/plans, such as Weight Watchers , Jenny Craig or similar plans are acceptablemethods of dietary management if there is concurrent documentation of at least monthly clinical encounters witha physician.Surgical InterventionThe NHLBI recommended weight-loss surgery as an option for carefully-selected adult patients with clinicallysevere obesity (BMI of 40 or greater; or BMI of 35 or greater with serious comorbid conditions) when lessinvasive methods of weight loss have failed and the patient is at high risk for obesity-associated morbidity ormortality. Surgica

This Coverage Policy addresses bariatric surgery and procedures for the treatment of morbid obesity. Coverage Policy . Coverage for bariatric surgery or revision of a bariatric surgery procedure varies across plans and may be governed by state mandates. Refer to t