C9785, Endoscopic outlet reduction, gastric pouch application, with endoscopy and
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Documentation Required
- Pre-operative psychological clearance by a licensed psychologist or psychiatrist is required for candidates with active substance abuse disorder, history of eating disorder or severe psychiatric disturbance, or those currently under care of a psychologist/psychiatrist — to assess suitability for surgery and ability to provide informed consent and comply with regimen.
- For complex revisional procedures (RNYNEJ, short-limb RNY reconstruction, Candy Cane resection): documentation of pre-operative diagnostic work-up including upper GI series, endoscopy (noting afferent limb filling and direct outlet), and that multiple diagnostic tools may be required because some tests may miss the diagnosis.
- Documentation of informed consent regarding experimental/limited-evidence procedures such as NOTES and novel endoscopic techniques, and that these are frequently recommended to be performed in research/experienced centers.
Key Coverage Criteria
- Inferred: Revisional bariatric procedures and endoscopic revision therapies for weight regain after Roux-en-Y gastric bypass (references to transoral outlet reduction (TORe), endoscopic suturing, StomaphyX, endoscopic and surgical gastrojejunal revision).
- Inferred: Endoscopic primary procedures and devices for obesity treatment (intragastric balloons, endoscopic sleeve gastroplasty, endoscopic duodenojejunal bypass liner/EndoBarrier, aspiration therapy/AspireAssist).
- Inferred: Bariatric/metabolic surgery as a treatment for type 2 diabetes in obese patients (multiple references to diabetes outcomes and metabolic surgery).
- Inferred: Management of bariatric surgical complications (references to management of leaks, stoma dilation, sclerotherapy, OTSC and stent strategies, endoscopic clips, and other endoscopic management techniques).
- Encounter for fitting and adjustment of gastric lap band (ICD-10: Z46.51) — listed as covered if selection criteria are met.
- Open or laparoscopic short or long-limb Roux-en-Y gastric bypass (RYGB), open or laparoscopic sleeve gastrectomy, open or laparoscopic biliopancreatic diversion (BPD) with or without duodenal switch (DS), laparoscopic adjustable silicone gastric banding (LASGB), open or laparoscopic single anastomosis duodenal-ileal switch (SADI-S), OR, open or laparoscopic sleeve gastrectomy with single anastomosis duodeno-ileal bypass (SIPS) is considered medically necessary when the selection criteria listed [...]
9 Active Policies
ANTHEM-CG-SURG-83, CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
AETNA-CPB-0157, Obesity Surgery
BCBSIL-SUR716.003, Bariatric Surgery
BCBSMT-SUR716.003, Bariatric Surgery
BCBSNM-SUR716.003, Bariatric Surgery
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