0316T
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical clearance within six months by the member’s PCP if no current cardiac or pulmonary comorbidities; if cardiac or pulmonary comorbidities present, clearance by a cardiologist and/or pulmonologist is required.
- Nutritional evaluation within six months by a qualified provider (physician, physician assistant, advanced registered nurse practitioner, or registered dietitian).
- Age-appropriate psychiatry/psychology consultation within six months stating the member is a good candidate for bariatric surgery and that any mental health disorders are adequately managed.
- Clinical documentation of the complication necessitating corrective surgery (e.g., operative notes, imaging, endoscopy confirming obstruction or strictures).
Key Coverage Criteria
- Hypertension that has not improved despite nonsurgical weight loss methods.
- Dyslipidemia that has not improved despite nonsurgical weight loss methods.
- Obstructive sleep apnea that has not improved despite nonsurgical weight loss methods.
- Surgical intervention should be considered only after documented failure of reasonable nonsurgical treatments.
- Bariatric surgery (LAGB, LSG, laparoscopic RYGB, BPD-DS/BPD-GRDS) is medically necessary when all criteria in sections A and B are met.
- Adults age ≥18 with BMI ≥32.5 kg/m² (South Asian, Southeast Asian, East Asian) or ≥35 kg/m² (all other ethnicities) when requesting LAGB, LSG, laparoscopic RYGB, or BPD-DS/BPD-GRDS.
1 Active Policy
AMBETTER-CP.MP.37 — Bariatric Surgery
Related Codes
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