E1332
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Gastric bypass and gastric restrictive procedures are consideredmedically necessarywhenallof the following criteria are met:
- Individual is age 18 years or older;and
- The recommended surgery is one of the following procedures:Biliopancreatic bypass with duodenal switch;orEndoscopic sleeve gastroplasty;orLaparoscopic adjustable gastric banding;orRoux-en-Y procedure up to 150 cm;orSingle anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S);orDuodenal jejunal bypass with gastric sleeve (DJB-SG);orSleeve gastrectomy;and
- Biliopancreatic bypass with duodenal switch;or
- Endoscopic sleeve gastroplasty;or
- Laparoscopic adjustable gastric banding;or
1 Active Policy
ANTHEM-CG-SURG-83 — CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
Related Codes
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