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.
