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-92, November 23, 2021
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 the TRICARE Program.
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,
the TRICARE
Program
will 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 the TRICARE Program.
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 the TRICARE Program.
5.0 LimitationS
5.1 Coverage
is limited to one bariatric surgery per lifetime, except in those
conditions addressed in
paragraph 4.3.3.
The limitation
of one bariatric surgery per lifetime refers only to bariatric surgical procedures
cost-shared by the TRICARE Program.
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.