CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity

This policy addresses bariatric/metabolic surgery and endoscopic treatments for clinically severe obesity. Coverage is considered medically necessary for adults (age ≥18) when the planned procedure is one of the following: Roux-en-Y gastric bypass (up to 150 cm), sleeve gastrectomy, biliopancreatic diversion with duodenal switch, single-anastomosis duodenal-ileal bypass with sleeve (SADI-S), duodenal-jejunal bypass with sleeve (DJB-SG), laparoscopic adjustable gastric banding, or endoscopic sleeve gastroplasty. It is not covered when policy criteria are not met, for BMI <35 kg/m², for endoluminal revision procedures (e.g., TORe, ROSE), or for other procedures such as one-anastomosis/mini gastric bypass.

"Gastric bypass and gastric restrictive procedures are consideredmedically necessarywhenallof the following criteria are met:"

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