E28.39 — Other primary ovarian failure
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Patient record must document BMI >= 35, at least one obesity-related comorbidity, and a primary diagnosis of morbid obesity (ICD-10-CM E66.01) for bariatric surgery claims.
- Documentation of prior conservative medical treatment: active participation within the 12 months prior to surgery in a physician- or healthcare professional-supervised weight-management program for a minimum of four consecutive months with monthly documentation of weight and BMI, current dietary regimen, and physical activity.
- A thorough multidisciplinary evaluation within the previous 6 months must include: (a) surgeon evaluation recommending the procedure and describing the proposed procedure, (b) separate non-surgeon physician medical evaluation with recommendation and medical clearance, (c) mental health/psychosocial clearance including a statement on motivation and ability to follow post-surgical requirements, and (d) nutritional evaluation by a physician or registered dietician.
Key Coverage Criteria
- Roux-en-Y gastric bypass (RYGBP) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
- Biliopancreatic diversion with duodenal switch (BPD/DS) or gastric reduction duodenal switch (BPD/GRDS) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
- Laparoscopic adjustable gastric banding (AGB) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
- Laparoscopic sleeve gastrectomy is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
- Bone mass measurement tests are covered when ordered by the treating physician or a qualified non-physician practitioner authorized by state law.
- An initial bone mass measurement is covered (Medicare reimbursement for an initial bone mass measurement may be allowed only once, regardless of sites studied).
11 Active Policies
AETNA-CPB-0327 — Infertility
AETNA-CPB-0599 — Autologous Skeletal Myoblast/Mononuclear Bone Marrow Cell Transplantation
AETNA-CPB-0787 — Comparative Genomic Hybridization (CGH)
ANTHEM-CG-LAB-21 — CG-LAB-21 Serum Iron Testing
A53026 — Billing and Coding: Bariatric Surgery Coverage
Related Codes
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