Subject: Bariatric Surgery and Other Treatments for Clinically Severe Obesity
Policy #: SURG.00024
Current Effective Date: 10/04/2016
Status: Revised
Last Review Date: 08/04/2016
Description/Scope
This document addresses surgical and other treatments for clinically severe obesity. Clinically severe obesity is a result of persistent and uncontrollable weight gain that constitutes a present or potential threat to life. There are a variety of surgical procedures and other treatment modalities intended for the treatment of clinically severe obesity.
Position Statement
Medically Necessary:
Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (for example, the Lap-Band® System or the REALIZE™ Adjustable Gastric Band), vertical banded gastroplasty, biliopancreatic bypass with duodenal switch, and sleeve gastrectomy (open or laparoscopic) are considered
medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet
ALL the following criteria (A, B, and C):
- BMI of 40 or greater, or BMI of 35 or greater with an obesity-related co-morbid condition including, but not limited to:
- diabetes mellitus; or
- cardiovascular disease; or
- hypertension; or
- life threatening cardio-pulmonary problems, (for example, severe obstructive sleep apnea, Pickwickian syndrome, obesity related cardiomyopathy) and
- The individual must have serially documented active participation in a non-surgical weight reduction regimen for at least 6 continuous months, in the 2 years prior to surgery, to enable both behavioral changes and adequate assessment of anticipated postoperative dietary maintenance. These efforts must be fully appraised and documented by the physician requesting authorization for surgery; and
- The physician requesting authorization for the surgery must provide documentation of ALL of the following (1 through 7):
- The individual's psychiatric profile is such that the candidate is able to understand, tolerate and comply with all phases of care and is committed to long-term follow-up requirements; and
- The candidate's post-operative expectations have been addressed; and
- The individual has undergone a preoperative medical consultation and is felt to be an acceptable surgical candidate; and
- The individual has undergone a preoperative mental health assessment and is felt to be an acceptable candidate; and
- The individual has received a thorough explanation of the risks, benefits, and uncertainties of the procedure; and
- The candidate's treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling; and
- The candidate's treatment plan includes counseling regarding exercise, psychological issues and the availability of supportive resources when needed.
Surgical repair following gastric bypass and gastric restrictive procedures is considered
medically necessary when there is documentation of a surgical complication related to the original surgery, such as a fistula, obstruction, erosion, disruption/leakage of a suture/staple line, band herniation, or pouch enlargement due to vomiting.
Repeat surgical procedures for revision or conversion to another surgical procedure (that is also considered medically necessary within this document) for inadequate weight loss, (that is, unrelated to a surgical complication of a prior procedure) are considered medically necessary when ALL the following criteria are met (A, B and C):
- The individual meets ALL the medical necessity criteria for bariatric surgery (see Criteria A thru C) (Note: Meeting the criteria for the initial bariatric surgery does not count toward meeting the criteria again for the repeat surgical procedure for revision or conversion to another surgical procedure.); and
- 2 years following the original surgery, weight loss is less than 50% of pre-operative excess body weight and weight remains at least 30% over ideal body weight (taken from standard tables for adult weight ranges based on height, body frame, gender and age, an example is available from the National Heart Lung and Blood Institute [NHLBI] at: http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm); and
- If inadequate weight loss or regain of initial weight loss following the initial surgery is determined to be due to noncompliance with the previously prescribed postoperative dietary and exercise programs, documentation is required to confirm that a mental health assessment has determined that behavioral issues that resulted in inadequate weight loss or regain, related to noncompliance with postoperative dietary and lifestyle modifications following the initial surgery, have been adequately addressed to significantly mitigate the risk of an inadequate weight loss outcome from the additional surgery.
Not Medically Necessary:
Stretching of a stomach pouch formed by a previous gastric bypass/restrictive surgery, due to overeating, does not constitute a surgical complication and the revision of this condition is considered
not medically necessary.
Investigational and Not Medically Necessary:
Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (for example, the Lap-Band® System or the REALIZE™ Adjustable Gastric Band), vertical banded gastroplasty, biliopancreatic bypass with duodenal switch, and sleeve gastrectomy (open or laparoscopic) are considered
investigational and not medically necessary when the criteria are not met.
Gastric bypass, using a Billroth II type of anastomosis (also known as a "mini gastric bypass") is considered
investigational and not medically necessary as a treatment of clinically severe obesity.
Bariatric surgical procedures including, but not limited to, laparoscopic adjustable gastric banding are considered
investigational and not medically necessary for individuals with a BMI of 30-34.9 kg/m².
Malabsorptive procedures including, but not limited to, jejunoileal bypass, biliopancreatic bypass without duodenal switch, or very long limb (greater than 150 cm) gastric bypass (other than the biliopancreatic bypass with duodenal switch) are considered
investigational and not medically necessary as a treatment of clinically severe obesity.
Repeat procedures for repair, revision, or conversion to another surgical procedure following a gastric bypass or gastric restrictive procedure are considered investigational and not medically necessary when the criteria are not met.
All other gastric bypass/restrictive procedures and other treatment modalities not listed above as medically necessary are considered
investigational and not medically necessary including, but not limited to, minimally invasive endoluminal gastric restrictive surgical techniques, such as use of the EndoGastric StomaphyX™ endoluminal fastener and delivery system, and laparoscopic gastric plication (laparoscopic greater curvature plication [LGCP]) with or without gastric banding, also the balloon systems, (such as the ReShape® Integrated Dual Balloon System) and vagus (or vagal) nerve blocking devices, (such as the MAESTRO® Rechargeable System).
Further Consideration:
A bariatric surgeon with experience in the pediatric population may request further consideration of a case of an individual under 18 years old with severe morbid obesity and unique circumstances by contacting a Medical Director.
(Further information available in the Rationale section of this document).
