Does 43281 require prior authorization?

Yes, 43281 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for 43281?

Medicare facility rate: $1424.88. Non-facility rate: $1424.88. Work RVU: 25.94.

Verity

`43281`

HCPCS/CPT

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Medicare Pricing

Work RVU

25.94

Facility

$1424.88

Non-Facility

$1424.88

Documentation Required

Thorough multidisciplinary evaluation within the previous 12 months that MUST include: a description of the proposed procedure(s); documentation of failure of weight loss by medical management; unequivocal clearance for bariatric surgery by a mental health provider; a nutritional evaluation by a physician, physician assistant, nurse practitioner or registered dietician.
Documentation of BMI values (height/weight) supporting BMI thresholds; provider attestation of Asian ethnicity when applying lower BMI thresholds for Asian patients.
For revisional/reoperation requests: documentation of band slippage or band component malfunction and documentation that the faulty component cannot be repaired when claiming band replacement/conversion; documentation of gastrointestinal symptoms (e.g., persistent nausea/vomiting, GERD) to justify gastric band removal (imaging evidence of obstruction not required).

Key Coverage Criteria

Adults (age ≥ 18): Bariatric surgery for the treatment of obesity is medically necessary when ALL of the following criteria are met: EITHER (a) BMI ≥ 35 kg/m² (class 2 obesity) (BMI ≥ 27.5 kg/m² in Asians when ethnicity is confirmed by provider attestation) OR (b) BMI 30–34.9 kg/m² (class 1 obesity) (BMI 25–27.4 kg/m² in Asians when ethnicity is confirmed by provider attestation) with at least one clinically significant obesity-related comorbidity (see list), AND a thorough multidisciplinary eva [...]
Adults: Clinically significant obesity-related comorbidities (examples listed) include: mechanical arthropathy in a weight-bearing joint (symptomatic degenerative joint disease in a weight bearing joint); diabetes mellitus; poorly controlled hypertension (SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg despite optimal medical management); hyperlipidemia; coronary artery disease; lower extremity lymphatic or venous obstruction; obstructive sleep apnea; pulmonary hypertension; evidence of fatty liver disease (M [...]
Initial bariatric surgical procedures (Adults) considered medically necessary when adult medical necessity criteria above are met (open or laparoscopic): Vertical band gastroplasty; Adjustable silicone gastric banding (e.g., LAP-BAND, REALIZE); Sleeve gastrectomy (stand-alone or staged); Roux-en-Y gastric bypass (Roux limb <150 cm and Roux limb >150 cm); Biliopancreatic diversion with duodenal switch (BPD/DS); Biliopancreatic diversion (BPD) without DS; Single-anastomosis duodenal-ileal bypass w [...]
Endoscopic sleeve gastroplasty (ESG) is considered medically necessary (codes listed).
Adjustment of an adjustable silicone gastric banding is medically necessary to control rate of weight loss and/or treat symptoms secondary to gastric restriction following a medically necessary adjustable silicone gastric banding procedure.
Reoperation/Revisional surgery (Adults) — medically necessary: Replacement of an adjustable silicone gastric band or separate or concurrent band removal and conversion to a second bariatric surgical procedure when there is evidence of band slippage or band component malfunction and the faulty component cannot be repaired; Gastric band removal for gastrointestinal symptoms (e.g., persistent nausea and/or vomiting, gastroesophageal reflux) with or without imaging evidence of obstruction; Surgical [...]

3 Active Policies

CIGNA-0051 — Bariatric Surgery and Procedures - (0051)

ANTHEM-CG-SURG-92 — CG-SURG-92 Paraesophageal Hernia Repair

REGENCE-SUR186 — Gastroesophageal Reflux Surgery

Have a follow-up question?

Ask Verity about documentation requirements, denial risks, or coverage in your state.

Medical clearance documentation (recommended elements cited by the policy / professional guidelines): comprehensive medical history, psychosocial history, physical examination, appropriate laboratory testing to assess surgical risk; GI evaluation in symptomatic patients (e.g., H. pylori screening, gallbladder evaluation, upper endoscopy when indicated); age- and risk-appropriate cancer screening; chest radiograph and standardized screening for obstructive sleep apnea (with confirmatory polysomnography if screening tests are positive) as indicated; tobacco cessation counseling/documentation (preferably cessation ≥6 weeks prior to surgery); noninvasive cardiac testing beyond ECG as indicated by individual risk; evaluation of the patient's ability to incorporate nutritional and behavioral changes before and after surgery; appropriate nutritional evaluation including micronutrient measurements before any bariatric surgical procedure (particularly for malabsorptive procedures); psychosocial-behavioral evaluation assessing environmental, familial and behavioral factors; formal mental health evaluation for any known or suspected psychiatric illness, substance abuse, or dependence prior to surgery.

43281