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.