43290
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
3.03
Facility
$157.32
Non-Facility
$2668.73
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; refer to the protocol titled Medical Records Documentation Used for Reviews. Preoperative evaluation that includes a detailed weight history along with dietary and physical activity patterns (required for adults under coverage criteria). Psychosocial-behavioral evaluation by an individual who is professionally recognized as part of a behavioral health discipline to provide screening and identification of risk factors or potential postoperative challenges that may contribute to a poor postoperative outcome (required for adults under coverage criteria) or participation in a Multidisciplinary surgical preparatory regimen (as an alternative per policy wording). For adolescents: evaluation at, or in consultation with, a Multidisciplinary center focused on the surgical treatment of severe childhood obesity (may include MBSAQIP-accredited adolescent centers or centers that demonstrate similar programmatic components). Evidence of OSA confirmation on polysomnography with an AHI or RDI of 63 30 when OSA is cited as a qualifying comorbidity. For obstruction: confirmation by imaging studies. For adjustable gastric band migration (slippage): records must demonstrate that manipulation or adjustment to correct band slippage has been attempted. For uncontrollable reflux related to sleeve gastrectomy: documentation of maximum nonpharmacological medical management failure; documentation of maximum pharmacological medical management failure (e.g., at least one month of double dose PPI, H2 blocker, and/or sucralfate); and endoscopy confirming severe esophagitis (grade C or D) despite maximum medical management. For planned two-stage procedures: documentation of initial BMI 63 50 kg/m2 prior to first stage, date of second stage (must be within 2 years), documentation of compliance with nutrition and exercise, and re-confirmation that individual meets medical necessity criteria at time of second stage procedure. For revisional procedures related to leaks, perforation, staple-line failure, mechanical device failure, etc.: operative, imaging, endoscopic, or pathology reports documenting the technical failure or major complication as the indication for revision. Comprehensive preoperative evaluation: "obesity-focused history, physical examination, and pertinent laboratory and diagnostic testing" (AACE/ASMBS guidance). Detailed weight history documenting prior attempts: "A detailed weight history should be documented, including a description of the onset and duration of obesity, the severity, and recent trends in weight... A brief summary of personal weight loss attempts, commercial plans, and physician-supervised programs should be reviewed and documented, along with the greatest duration of weight loss and maintenance." (AACE/ASMBS guidance). Evidence of failure of conservative measures where relevant: many device and guideline recommendations require that patients have "failed conservative weight reduction strategies" (e.g., ORBERA indication: failed supervised diet, exercise, and behavior modification). Psychosocial / behavioral health assessment: "all bariatric surgery candidates be evaluated by a licensed mental health care provider experienced in the treatment of severely obese patients" and preoperative psychosocial evaluation per ASMBS (Sogg et al., 2016). Multidisciplinary team involvement and plan for long-term follow-up: multiple society recommendations require multidisciplinary care (medical, nutritional, psychological, exercise counseling) and an established mechanism for long-term follow-up care (ASGE, ASMBS, NICE, ADA). Preoperative nutritional assessment and recommended perioperative nutritional monitoring: ASMBS recommends preoperative screening for vitamin deficiencies and that long-term monitoring of micronutrient and nutritional status be provided after surgery (Parrott et al., 2017; ADA 2024 statement). Informed consent describing device- and procedure-specific risks, tolerance issues, potential for early device removal, and potential for weight regain: ASMBS addendum on intragastric balloons and other sections emphasize informed consent and counseling about adverse events and expected postoperative course. For procedures performed under research or limited-use guidance (e.g., DJBL / EndoBarrier per NICE): documentation of research governance, patient selection criteria, complications, reasons for early removal, medication use while device in place and after removal, and diabetes control after removal are required to meet research-use recommendations. For FDA-labeled device indications (e.g., TPS, ORBERA): documentation that device use conforms to labeled inclusion criteria (age, BMI range, presence of comorbidities as applicable) and that device is used "in conjunction with a diet and behavior modification program." Perioperative and postoperative visit and monitoring schedules described in RCTs/devices (examples): e.g., ESG MERIT trial: 12 follow-up visits in first year (weeks 1 and 4, then every 4 weeks until 52 weeks). Documentation of follow-up attendance and outcomes may be required to support continued device use or coverage.
Key Coverage Criteria
- The following bariatric surgical procedures are proven and medically necessary for treating obesity: Biliopancreatic diversion/biliopancreatic diversion with duodenal switch; Gastric bypass (includes robotic-assisted gastric bypass); Adjustable gastric banding (using open or laparoscopic approaches) for individuals 63; Sleeve gastrectomy (vertical sleeve gastrectomy). [...]
- "MBS is recommended for individuals with a BMI ≥ 35 kg/m², regardless of presence, absence, or severity of comorbidities" (ASMBS/IFSO update).
- "MBS should be considered for individuals with metabolic disease and BMI of 30-34.9 kg/m²" (ASMBS/IFSO update).
- ADA Standards: "metabolic surgery should be considered as a weight and glycemic management approach for individuals with diabetes with a BMI ≥ 30.0 kg/m² (or ≥ 27.5 kg/m² in Asian American individuals) who are otherwise good candidates for surgery." AACE/ACE/AACE-ASMBS recommendations: "Patients with a BMI ≥ 40 kg/m² without coexisting medical problems ... eligible; Patients with a BMI ≥ 35 kg/m² and one or more severe obesity-related complications remediable by weight loss ... [...]
- Gastric bypass and gastric restrictive procedures are consideredmedically necessarywhenallof the following criteria are met:
- Individual is age 18 years or older;and
6 Active Policies
AMBETTER-CP.MP.37 — Bariatric Surgery
UHC-POL-bariatric-surgery — Bariatric Surgery
UMR-POL-UMR-bariatric-surgery — Bariatric Surgery
SUREST-POL-SUREST-bariatric-surgery — Bariatric Surgery
ANTHEM-CG-SURG-83 — CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
Related Codes
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