biliopancreatic bypass; a surgical procedure involving a gastric restriction diverting bile and pancreatic juice into the distal ileum.

Transcription

1 SURGERY FOR MORBID OBESITY SUR COVERAGE: Surgical procedures which may be eligible for coverage for the treatment of morbid or clinically severe obesity are: 1. Vertical banded gastroplasty (gastric stapling or gastroplasty) and related techniques consisting of constructing a small pouch with a restricted outlet along the lesser curvature of the stomach. The outlet may be externally reinforced to prevent disruption or dilation. 2. Gastric bypass procedures involves constructing a proximal gastric pouch whose outlet is a Y-shaped limb of small bowel of varying lengths (Roux-en-Y gastric bypass). The following surgeries are considered experimental: jejunoileal bypass; any surgical procedure that shunts ingested food from the jejunum into the ileum thus bypassing a majority of the small intestine. biliopancreatic bypass; a surgical procedure involving a gastric restriction diverting bile and pancreatic juice into the distal ileum. gastric wrapping; a surgical procedure in which the stomach is folded over on itself and a full stomach wrap (polypropylene mesh) is applied. gastric banding; a gastric restrictive surgical procedure utilizing a synthetic band rather than staples to divide the stomach into a small upper pouch and a lower portion. Garren-Edwards gastric bubble; a device made of elastomeric plastic and placed in the stomach via a gastroscope. It is a free floating intragastric bubble used to reduce stomach capacity. DESCRIPTION: Morbid or clinically severe obesity is a result of persistent and uncontrollable weight gain that constitutes a present or potential threat to life. Clinically severe obesity is defined as a weight which is at least 100 pounds over the ideal weight for frame, age, height and sex specified in the most recently published Metropolitan Life Insurance Height and Weight Table. Clinically severe obesity may also be defined by body mass index (BMI). BMI= [weight (kilograms)/height (meters) squared]. A BMI of 40 kg/meter squared or greater represents clinically severe obesity.

2 (Refer to the policy on Medical Management of Obesity for the height and weight or BMI table) There are a variety of surgical procedures intended for the treatment of clinically severe obesity. All are based on one of two premises: alteration of the intestinal absorption limiting nutrients available to the body or reduction in the capacity of the stomach thereby limiting the amount of food ingested. POLICY: The screening criteria listed below should be utilized to determine if conservative treatment has been tried and has failed. Criteria includes: 1. Weight must be at least 100 pounds over the ideal weight for frame, age, height and sex OR have a BMI of 40 kg/meter squared or greater 2. The condition of clinically severe obesity must be of at least five years duration 3. Nonsurgical methods of weight reduction must have been unsuccessfully attempted for at least five years under physician supervision. Surgical procedures which may be considered for the treatment of clinically severe obesity are: 1. Vertical banded gastroplasty (gastric stapling or gastroplasty) and related techniques consisting of constructing a small pouch with a restricted outlet along the lesser curvature of the stomach. The outlet may be externally reinforced to prevent disruption or dilation. 2. Gastric bypass procedures involve constructing a proximal gastric pouch whose outlet is a Y-shaped limb of small bowel of varying lengths (Roux-en-Y gastric bypass). The following surgeries are considered experimental: jejunoileal bypass - any surgical procedure that shunts ingested food from the jejunum into the ileum thus bypassing a majority of the small intestine. biliopancreatic bypass - a surgical procedure involving a gastric restriction diverting bile and pancreatic juice into the distal ileum. gastric wrapping - a surgical procedure in which the stomach is folded over on itself and a full stomach wrap (polypropylene mesh) is applied. gastric banding - a gastric restrictive surgical procedure utilizing a synthetic band rather than staples to divide the stomach into a small upper pouch and a lower portion.

3 Garren-Edwards gastric bubble - a device made of elastomeric plastic and placed in the stomach via a gastroscope. It is a free floating intragastric bubble used to reduce stomach capacity. SECOND OPERATION DUE TO COMPLICATIONS: After a patient has had an approved surgical procedure for obesity, he/she may require a second surgery because of complications. The surgeon, in many cases, will do a gastric bypass, gastric stapling or gastroplasty to help the patient avoid regaining the weight that was lost. In this situation, payment is authorized even though the patient's condition may not meet the definition of morbid obesity/clinically severe obesity because of the weight that was previously lost following the initial surgery. TABLE 1: Body Weights in Pounds According to Height and Body Mass Index Each entry gives the body weight in pounds (lbs) for a person of a given height and body mass index. Pounds have been rounded off. To use the table, find the appropriate height in the left hand column. Move across the row to a given weight. The number at the top of the column is the body mass index for the height and weight. Body Mass Index (kg/m 2 ) BMI HT (in.) Body Weight (lbs) Adapted with permission from Bray, G.A., Gray, D.S. Obesity. Part 1. Pathogenesis. West J. Med. 1988; 149: METROPOLITAN HEIGHT AND WEIGHT TABLES ACCORDING TO FRAME, AGES 25-59

4 MEN: Height (in shoes) WEIGHT IN POUNDS (IN INDOOR CLOTHING) Feet Inches Small Frame Medium Frame Large Frame WOMEN: Height (in shoes) WEIGHT IN POUNDS (IN INDOOR CLOTHING) Feet Inches Small Frame Medium Frame Large Frame Indoor clothing weighing 5 pounds for men and 3 pounds for women. Shoes with 1-inch heels. Source of basic data Build Study, Society of Actuaries and Association of Life Insurance Medical Directors of America, Copyright 1983 Metropolitan Life Insurance Company Courtesy of the Metropolitan Life Insurance Company NOTE: If claims are submitted in kilograms(kg) or centimeters(cm), use the following conversions: 1 kg equals 2.2 lbs cm equals 1 inch DISCLAIMER:

5 State and federal law, as well as contract language, including definitions and specific inclusions/exclusions, takes precedence over Medical Policy and must be considered first in determining coverage. The member s contract benefits in effect on the date that services are rendered must be used. Any benefits are subject to the payment of premiums for the date on which services are rendered. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. HMO Blue Texas physicians who are contracted/affiliated with a capitated IPA/medical group must contact the IPA/medical group for information regarding HMO claims/reimbursement information and other general polices and procedures. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company* Southwest Texas HMO, Inc.* d/b/a HMO Blue Texas * Independent Licensees of the Blue Cross and Blue Shield Association Posted Jan. 7, 2003