Chapter 4
Section 13.2
Surgery For Morbid Obesity
Issue Date: November 9, 1982
Copyright: CPT
only © 2006 American Medical Association (or such other date of
publication of CPT).
All Rights Reserved.
Revision: C-18, February 21, 2018
1.0 CPT
PROCEDURE CODEs
43633, 43644, 43645, 43770
- 43775, 43842, 43845 - 43848
2.0 HCPCS
Procedure Code
S2083
3.0 DESCRIPTION
3.1 Surgery
for morbid obesity, termed bariatric surgery, is based on two principles:
• Divert
food from the stomach to a lower part of the digestive tract where
the normal mixing of digestive fluids and absorption of nutrients
cannot occur (i.e., malabsorptive surgical procedures); or
• Restrict the size
of the stomach and decrease intake (i.e., restrictive surgical procedures). Surgery
can combine both types of procedures.
3.2 Bariatric
surgery is performed for the treatment of morbid obesity. Morbid
obesity is a Body Mass Index (BMI) equal to or greater than 40 kilograms
per meter squared (kg/m2), or a BMI equal to or greater than 35
kg/m2 in conjunction with high-risk co-morbidities, which is based
on the guidelines established by the National Heart, Lung and Blood
Institute on the Identification and Management of Patients with
Obesity.
3.3 BMI, which describes relative weight for height,
is significantly correlated with total body fat content and is a
practical indicator of the severity of obesity with a direct calculation
based on height and weight regardless of gender. BMI is equal to
weight in kilograms divided by height in meters squared.
4.0 POLICY
4.1 Bariatric
surgery, using a covered procedure outlined in
paragraph 4.2 is covered for
the treatment of morbid obesity when all the following conditions
are met:
4.1.1 The patient has completed growth (18 years
of age or documentation of completion of bone growth).
4.1.2 The patient
has been previously unsuccessful with medical treatment for obesity.
Failed attempts at non-surgical medical treatment for obesity must
be documented in the patient’s medical record.
4.1.2.1 Commercially
available diet programs or plans, such as Weight Watchers®, Jenny
Craig, or similar plans are acceptable methods of dietary management,
if there is concurrent documentation of at least monthly clinical
encounters with the physician.
Note: These programs
are not covered by TRICARE.
4.1.2.2 Physician-supervised
programs consisting exclusively of pharmacological management are not
sufficient to meet this requirement.
4.1.3 The patient
has evidence of
either of the following:
• A
body-mass index greater than or equal to 40 kg/m2.
• A body-mass index
of 35-39.9 kg/m2 with one clinically significant co-morbidity, including
but not limited to, cardiovascular disease, type 2 diabetes mellitus, obstructive
sleep apnea, pickwickian syndrome, hypertension, coronary artery
disease, obesity-related cardiomyopathy, or pulmonary hypertension.
4.2 When
the specific medical necessity criteria stated in
paragraph 4.1 have
been met for bariatric surgery, TRICARE shall cost share any of
the following open or laparoscopic surgical procedure:
• Roux-en-Y
gastric bypass
• Vertical
banded gastroplasty
• Gastroplasty (stomach
stapling)
• Adjustable gastric
banding (i.e., adjustable LAP-BAND®)
• Biliopancreatic
diversion with or without duodenal switch for individuals with a
BMI greater than or equal to 50 kg/m2
• Sleeve
Gastrectomy
• Stand-alone laparoscopic
sleeve gastrectomy
4.3 Revision Bariatric Surgery
4.3.1 Medically
necessary surgical reversal (i.e., takedown or revision) of the
bariatric procedure is covered when the beneficiary develops a complication
(e.g., stricture or obstruction) from the original covered surgery.
4.3.2 Replacement
of an adjustable band because of complications (e.g., port leakage,
slippage) that cannot be corrected with band manipulation or adjustments
is covered.
4.3.3 Repeat/revision
of a covered bariatric surgical procedure due to technical failure
of the original procedure is covered when all of the following criteria
are met:
• The
patient has failed to achieve adequate weight loss, which is defined
as failure to lose at least 50% of excess body weight or failure
to achieve body weight to within 10% of ideal body weight at least
two years following the original surgery.
• The patient met all
the screening criteria, including BMI requirements of the original procedure,
and has been compliant with a prescribed nutrition and exercise
program following the original surgery.
• The requested procedure
is a covered bariatric surgery.
Note: Inadequate weight loss due to individual noncompliance
with postoperative nutrition and exercise recommendations is not
a medically necessary indication for revision or conversion surgery and
is not payable under TRICARE.
4.4 Any device
utilized for a bariatric surgical procedure must have the U.S. Food
and Drug Administration (FDA) approval specific to the indication,
otherwise the device is considered unproven and not payable under
TRICARE.
5.0 LimitationS
5.1 Coverage
is limited to one bariatric surgery per lifetime, except in those
conditions addressed in
paragraph 4.3.3.
5.2 The following are examples
of conditions that are always denied a second bariatric surgical procedure
because they do not qualify as a complication or technical failure:
5.2.1 Weight
gain or weight plateau resulting from failure to follow the regimen
of diet and exercise recommended after the initial bariatric surgery.
5.2.2 Weight
gain or weight plateau resulting from the dilation and other stabilization
of the gastric pouch as a natural and ordinary occurrence in the
aftermath of the initial bariatric surgery.
6.0 Policy
Considerations
Benefits are authorized for
otherwise covered medical services and supplies directly related
to complications of obesity when such services and supplies are
an integral and necessary part of the course of treatment that was
aggravated by the obesity (e.g., excision of redundant skin folds
after weight loss in areas such as, but not limited to, the abdomen,
lumbar region, arms, and/or thighs). TRICARE payment shall be considered
for medically necessary services when the beneficiary has met the
following criteria:
6.1 The beneficiary had a covered
bariatric surgical procedure with subsequent weight loss, is at least
18 months postoperative, and has maintained weight for at least
six months.
6.2 The beneficiary’s medical record documents
a redundant skin fold or excessive skin that significantly interferes
with mobility (e.g., a large hanging abdominal pannis - a Grade
2 panniculus or greater) or causes a physical functional impairment
such as uncontrollable inflammation and/or infection resulting in
pain, ulceration, or otherwise complicates medical conditions, persistent
and refractory to medical treatment. (Examples of agents that may
be used for conservative treatment are antifungal, antibacterial
or moisture-absorbing agents, topically applied skin barriers, and
supportive garments.)
Note: In this policy,
physical functional impairment means a limitation from normal (or
baseline) of physical functioning that may include, but is not limited
to, problems with ambulation, mobilization, skin integrity, or distortion
of nearby body parts. Physical functional impairment excludes social, emotional
and psychological impairments or potential impairments.
7.0 EXCEPTIONS
7.1 Benefits
for adjustments to the gastric banding device by injection or aspiration
of saline, including any adjustment-related complications, shall
be allowed for patients who underwent the laparoscopic adjustable
gastric banding (i.e., LAP-BAND®) surgery before the effective date
of coverage only if the patient criteria discussed in
paragraph 4.1 were
met or would have been met at the time of surgery.
7.2 TRICARE
will not cost-share any complication resulting from the initial
surgery, including band-related complications, for those patients
who surgeries were performed prior to the effective date of coverage.
If, however, a complication results from a separate medical condition,
benefits shall be allowed for the otherwise covered treatment. A
separate medical condition exists when it causes a systemic effect,
or occurs in a different body system from the noncovered treatment.
7.3 Documentation
must be submitted that gives the patient’s history and shows that
the patient met or would have met the criteria for the morbid obesity
benefit at the time of surgery. The contractor shall conduct a medical
review to assure compliance with
paragraph 4.1. Where necessary, additional clinical
documentation shall be obtained as part of this review.
8.0 EXCLUSIONS
8.1 Nonsurgical
treatment related to obesity, morbid obesity, or weight reduction
(e.g., weight control services, weight control/loss programs, exercise
programs, food supplements, weight loss drugs, etc.).
8.2 Redundant
skin surgery when performed solely for the purpose of improving
appearance or to treat psychological symptomatology or psychosocial
complaints related to one’s appearance.
8.3 Gastric bubble or balloon for treatment of
morbid obesity is unproven.
8.4 Gastric wrapping/open gastric banding for treatment
of the morbid obesity is unproven.
8.5 Unlisted CPT procedure codes 43659 (laparoscopy
procedure, stomach); 43999 (open procedure, stomach); and 49329
(laparoscopy procedure, abdomen, peritoneum and omentum) for gastric
bypass procedures.
9.0 EFFECTIVE
Dates
9.1 Laparoscopic surgical procedure for gastric
bypass and gastric stapling (gastroplasty), including vertical banded
gastroplasty are covered, effective December 2, 2004.
9.2 Laparoscopic
adjustable gastric banding is covered, effective February 1, 2007.