Oxford Health Plans > Providers' Resources > Medical & Administrative Policies > Gastric Surgery for Obesity
Title of Medical Policy

Gastric Surgery for Obesity

The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Oxford Medicare Advantage Members. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.

Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.

Coverage Statement

Policy is applicable to:

    Commercial plans

    Oxford Medicare Advantage® plans, including Medicare Group Accounts (MGA)

Conditions of Coverage

Benefit Type General benefits package
BEH benefits for 90801
Referral Required
(Does not apply to non-gatekeeper products)
No 1
Authorization (Precertification always required for inpatient admission) Yes 2
Precertification with MD Review No 3,4
Site(s) of Service
(If not listed, MD Review required)
Inpatient, Outpatient
Special Considerations 1CPT codes 90772 and S2083 require referral only if performed in the office.
2Authorization is not required for 90801 for Dx 799.9.
3 MD review is always required if the Member's BMI is less than 40.
4 MD review is always required for Lap-Band procedures if the Member's BMI is greater than 40 but the surgeon is not on the Providers with INAMED/Bio-Enterics Training list

Description of Service, Assessment, and Background Information

Obesity is a condition in which excess body fat may put a person's health at risk. Excess body fat results from the body's inability to balance caloric intake with energy expenditure. According to the National Health and Nutrition Examination Survey (NHANES), 33% of adults in the United States are obese.

Measures of Obesity:
Body Mass Index (BMI) has become the medical standard used to define obesity. BMI is an estimate used to determine if a person may be at health risk due to excessive weight. BMI is defined as weight (in kilograms) divided by height (in meters) squared. Healthful weights have been defined as those associated with BMI's of 19 to 24, the range of lowest statistical health risk. Individuals with a BMI of 25 to 29.9 are considered overweight, while individuals with a BMI of 30 or greater are considered obese with potentially significant health risks.

There are three types of surgical procedures currently recognized by the 1991 NIH Consensus Conference for the management of severe obesity:

  • Vertical banded Gastroplasty (CPT 43842) and other forms of Gastroplasty (43843) - procedures designed to restrict food intake by limiting gastric volume. A 15-ml gastric reservoir is created by one of several stapling techniques. The small gastric reservoir empties through a narrow channel on the lesser curvature of the stomach to the residual stomach. The channel is reinforced with a prosthetic material to ensure a channel circumference of 4.5 to 5 cm. This operation is attractive because it preserves gastroduodenal continuity and avoids the potential for micronutrient deficiencies.

  • Gastric Bypass (CPT 43846, 43847) and Laparoscopic Gastric Bypass (CPT 43644 and 43645) - procedures that also limit the gastric reservoir capacity by the creation of a 15 ml stapled gastric pouch. However, the stapled pouch is connected by a 10-mm anastamosis to a 40-cm Roux-en-Y jejunal limb, thus bypassing the distal stomach, duodenum, and very proximal jejunum. This procedure combines gastric restriction with emptying of semisolid gastric contents into the jejunum, which seems to exert further additional limitation of food intake.

  • Laparoscopic placement of an adjustable gastric band (Lap-Band), (CPT 43770) which is a silicone implant in the shape of a ring, with an adjustable balloon. The band is placed just below the esophago-gastric junction, and the balloon is connected to a reservoir under the skin. The degree of gastric restriction can be adjusted by accessing the reservoir through the skin and adding or removing saline (CPT 90772 or HCPCS S2083).

Policy and Rationale

Oxford® will cover Gastric Surgery for the treatment of obesity following Medical Director review, as defined under Treatment/Application Guidelines.

Criteria for Coverage
Medical Director review is not required when:
  1. The Member's BMI is 40 or above and the requested procedure is Vertical banded Gastroplasty (CPT 43842, 43843), Gastric Bypass (CPT 43846, 43847) or Laparoscopic Gastric Bypass (CPT 43644 and 43645). or
  2. The Member's BMI is 40 and above and the request is for Lap-Band (CPT 43770) and the surgeon is on the Providers with INAMED/Bio-Enterics Training list.

Medical Director Review is required when:
  1. The Member's BMI is 40 or above and the request is for Lap-Band (CPT 43770) and the surgeon is not on the Providers with INAMED/Bio-Enterics Training list. or
  2. The Member's BMI is less than 40.

Additional information for Medical Director review:

Surgical treatment of obesity should be limited to persons with:
  • BMI of 40 or more, which means about 100 pounds of overweight for men and about 80 pounds for women. This indicates a person is severely obese and therefore, a candidate for surgery.
  • BMI between 35 and 39.9 who have at least one accompanying weight-related comorbid factor are candidates for this procedure:
    • Weight related disabling joint disease; or
    • Pulmonary hypertension of obesity; or
    • Coronary artery disease; or
    • Insulin-resistant type II diabetes

Laparoscopic placement of an adjustable gastric band (Lap-Band), (CPT 43770): As required by the Food and Drug Administration (FDA), use of this procedure and implant is restricted to surgeons who have obtained a certificate from the manufacturer (INAMED) attesting to their qualifications to perform this procedure. For Members who meet criteria for gastric surgery, and for whom, the surgeon requests placement of the Lap-Band, the surgeon must provide copies of:
  1. A certificate attesting to their completion of the INAMED/Bio-Enterics Training Program for Lap Band, AND
  2. A letter from a INAMED/Bio-Enterics-sponsored proctor attesting to the surgeon's proficiency in performing the Lap-Band procedure.

Additional Guidelines

Recommended Qualifications for Surgeons (except for Lap-Band procedures):

  1. Board certified in General Surgery by the American Board of Surgery and
  2. Has completed a fellowship in Bariatric Surgery, during which he/she has performed at least 25 bariatric cases and
  3. Performs at least 25 bariatric cases a year in clinical practice and
  4. Has performed at least 100 bariatric cases following fellowship and
  5. Performs the surgery in hospitals that meet criteria for bariatric care and
  6. Has at least 25 CME credits every two years in Bariatric Surgery and
  7. Has in place a structured program for following his/her bariatric patients.

If the surgeon is requesting an open bariatric procedure, then the above criteria should be met in his/her experience with open cases. Similarly, if the request is for a laparoscopic procedure, the above criteria should be met by his/her experience in laparoscopic procedures.

Recommended qualifications for facilities:

  1. Have a bariatric surgical team led by a surgeon meeting requirements for bariatric surgery and
  2. Have a specially equipped operating room for bariatric surgery, including tables and ancillary equipment, which can accommodate the morbidly obese and
  3. Have anesthesiologists who are experienced in bariatric surgery and who are regularly assigned to bariatric procedures as part of the bariatric surgical team and
  4. Have a recovery room and ICU capable of providing critical care for obese patients and
  5. Have hospital beds, adjustable air pressure mattresses, commodes, stretchers, and wheelchairs to accommodate morbidly obese patients, as well as wider doorframes and modified bathroom facilities and
  6. Have radiology and other diagnostic modalities capable of handling morbidly obese patients and
  7. Can provide perioperative care including rehabilitation, psychiatric care, nutritional counseling and nursing care for bariatric patients and
  8. Have an institutional commitment to maintain and upgrade facilities, equipment and services to support a bariatric program.

BEH evaluation:

Oxford does not require a psychological evaluation prior to Gastric Surgery for obesity, but will reimburse one visit for a psychological evaluation, if requested.

Payment Guidelines:

If Lap Band procedures are performed using a laparoscopic method providers should bill using either the unlisted CPT code 43770.
  • Note: If requested, the use of an Assistant Surgeon for CPT the Lap Band is appropriate, and the name of the assistant surgeon should be listed in the Authorization.

    If the assistant surgeon was not authorized, and the site of service is not inpatient, the reimbursement for the assistant surgeon should be denied.

Adjustment of the gastric Lap Band by injection or aspiration of saline (90772/S2083) is included in the gastric Lap Band surgery (43770) when performed within the 90-days following the surgery.

.
Applicable ICD-9 Codes

ICD-9 Code Description
44.68 Laparoscopic gastroplasty
44.95 Laparoscopic gastric restrictive procedure
44.96 Laparoscopic revision of gastric restrictive procedure
44.97 Laparoscopic removal of gastric restrictive device(s)
44.98 (Laparoscopic) adjustment of size of adjustable gastric restrictive device
278.01 Morbid obesity
V85.3 Body Mass Index between 30-39, adult
V85.30 Body Mass Index 30.0-30.9, adult
V85.31 Body Mass Index 31.0-31.9, adult
V85.32 Body Mass Index 32.0-32.9, adult
V85.33 Body Mass Index 33.0-33.9, adult
V85.34 Body Mass Index 34.0-34.9, adult
V85.35 Body Mass Index 35.0-35.9, adult
V85.36 Body Mass Index 36.0-36.9, adult
V85.37 Body Mass Index 37.0-37.9, adult
V85.38 Body Mass Index 38.0-38.9, adult
V85.39 Body Mass Index 39.0-39.9, adult
V85.4 Body Mass Index 40 and over, adult

Applicable CPT Codes

CPT Code Description
43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
43645 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption
43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components)
43771 Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric band component only
43772 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric band component only
43773 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric band component only
43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric band and subcutaneous port components
43842 Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty
43843 Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty
43845 Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch)
43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy
43847 Gastric restrictive procedure, with gastric bypass for morbid obesity; with small bowel reconstruction to limit absorption
43848 Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric band (separate procedure)
43886 Gastric restrictive procedure, open; revision of subcutaneous port component only
43887 Gastric restrictive procedure, open; removal of subcutaneous port component only
43888 Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only

Applicable HCPCs codes:

HCPCS codes Description
S2083 Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline
90772 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

BEH evaluation:
Applicable ICD-9 code:

Applicable ICD-9 code: Description
799.9 Other unknown and unspecified cause

Applicable CPT code:

Applicable CPT code: Description
90801 Psychiatric diagnostic interview examination

References

  1. New York Health Plans Obesity Surgery Workgroup, Surgical Management of Obesity Consensus Guideline. May 2004.

  2. American Medical Association. Current Procedural terminology: CPT 2006, Professional Edition, AMA Press, 2005.

  3. American Medical Association. Healthcare Common Procedure Coding System. Medicare's National Level II Codes HCPCS 2006. AMA Press 2005.

  4. ECRI Hotline Response™: Safety and Efficacy of Surgical Revision or Reoperation for Gastroplasty/ Gastric Bypass Surgery for Morbid Obesity. Updated August 7, 2002. Retrieved 3-17-2003.

  5. ECRI Hotline Response ™: Laparoscopic Roux -En-Y Gastric Bypass for Morbid Obesity. Updated August 8, 2002. Retrieved 3-17-2003.

  6. ECRI Hotline Response ™: Laparoscopic Loop Gastric Bypass (Mini-Gastric Bypass) for Morbid Obesity. Updated June 10, 2002. Retrieved 3-17-2003.

  7. ECRI Hotline Response ™: Laparoscopic Gastric Banding for Morbid Obesity. Updated July 2, 2002. Retrieved 3-17-2003.

  8. ECRI Hotline Response ™: Silastic Ring Vertical Gastric Bypass Surgery (Fobi Pouch) for Treatment of Morbid Obesity. Updated July 7, 2002. Retrieved 3-17-2003.

  9. American Society for Bariatric Surgery: Gastric restrictive surgery for morbid obesity. (1994 Jun (revised 2000 Jun)) [Technology a: reports] [X39548].

  10. American Dietetic Association. (1996). Position of the American Dietetic Association: Weight Management.

  11. Milliman Care Guidelines 9th Edition, 2005. Org: S-512 (SC) Gastric Restrictive Procedure with Gastric Bypass.

  12. Milliman Care Guidelines 9th Edition, 2005. Org: S-514 (SC) Gastric Restrictive Procedure without Gastric Bypass.

  13. Medicare Coverage Issues Manual. Section 35-26. "Treatment of Obesity". Retrieved 3-17-2003. Medicare Coverage Issues Manual. Section 35-86. "Gastric Balloon for Treatment of Obesity". Retrieved 3-17-2003.

  14. Medicare Coverage Issues Manual. Section 35-40. "Gastric Bypass Surgery for Obesity". Retrieved 3-17-2003.

  15. Empire Medicare New Jersey Policy. "Obesity". (G-24A). Dated March 25, 1996. Retrieved 3-17-2003.

  16. Benotti PN, Forse RA. (1995). The role of gastric surgery in the multidisciplinary management of severe obesity. Am J Surg. Mar; 169(3): 361-7.

  17. Deitel M. (1994). Editorial: surgery for clinically severe obesity. J Am Coll Nutr. Aug; 13(4): 307-8.

  18. Lonroth H, Dalenbeck J, Haglind E, Josefsson K, Olbe L, Fagevik OM, Lundell L. (1996). Vertical banded gastroplasty by laparoscopic technique in the treatment of morbid obesity. Surg Laparosc Endosc. Apr; 6(2): 102-7.

  19. National Institutes of Health. (1996). Gastric Surgery for Severe Obesity. NIH Publication No. 96-4006.

  20. Reinhold RB. (1994). Late results of gastric bypass surgery for morbid obesity. J Am Coll Nutr. Aug; 13(4): 326-31.

  21. Sagar PM. (1995). Surgical treatment of morbid obesity. Br J Surg. Jun; 82(6): 732-9.

  22. Balsiger, BM, Murr, MM, Poggio, JL, and Sarr, MG, Bariatric Surgery, Surgery for Weight Control in Patients with Morbid Obesity, Medical Clinics of North America, Vol. 84, Number 2, March 2000, pp.

  23. Milliman Care Guidelines 9th Edition, 2005. Org: S-513 (SC) Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy.

  24. Milliman Care Guidelines 9th Edition, 2005. Org: S-515 (SC) Gastric Restrictive Procedure without Gastric Bypass by Laparoscopy

# SURGERY 029.7 T2
Effective Date: June 1, 2006