Bariatric Surgery

This policy covers laparoscopic bariatric procedures (LAGB, LSG, laparoscopic RYGB, BPD‑DS/BPD‑GRDS) when specific medical criteria are met for adults and selected adolescents. Coverage is limited to patients who meet both sections A and B — including ethnicity‑ and age‑specific BMI thresholds (e.g., adults ≥32.5 kg/m² for some Asian groups or ≥35 kg/m² for others, with lower‑BMI qualifications if significant obesity‑related comorbidities such as T2DM, hypertension, OSA, NAFLD, etc., are present), documentation of failed nonsurgical weight‑loss attempts, completion of required preoperative evaluations/clearances within six months, and excludes investigational procedures and uses (with LAGB not FDA‑approved for adolescents and revisions/repeats required to meet original criteria).

"Bariatric surgery (LAGB, LSG, laparoscopic RYGB, BPD-DS/BPD-GRDS) is medically necessary when all criteria in sections A and B are met."