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-9, July 24, 2024
1.0 CPT CODES
43633, 43644, 43645, 43770
- 43775, 43842, 43845 - 43848
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 The
contractor shall ensure failed attempts at non-surgical
medical treatment for obesity
must be are documented
in the patient’s medical record.
4.1.2.1 CommerciallyThe
contractor shall accept 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 byThe TRICARE Program
does not cover these commercially available diet programs or plans.
4.1.2.2 PhysicianThe
contractor shall not accept physician-supervised programs
consisting exclusively of pharmacological management are
not as 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
shall 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
The
TRICARE Program covers:
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 used for
a bariatric surgical procedure must have the that
has United States (US) Food and Drug Administration
(FDA) approval specific to the indication,.otherwise 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 The
contractor shall cover 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 The contractor shall conduct
a medical review to assure compliance with
paragraph 4.1 and when needed,
obtain additional clinical documentation.
Documentation
must be submitted The contractor shall
require documentation 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.
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).
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 Current Procedural
Terminology (CPT) 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.
