PRIOR AUTHORIZATION Preauthorization is required for BlueCHiP for Medicare and recommended for all other BCBSRI products.

Transcription

1 Medical Cverage Plicy Bariatric Surgery sad EFFECTIVE DATE: 10/15/2013 POLICY LAST UPDATED: 07/05/2012 OVERVIEW Bariatric surgery is perfrmed fr the treatment f mrbid (clinically severe) besity. Mrbid besity is defined as a bdy mass index (*BMI) greater than 40 kg/m2 r a BMI greater than 35 kg/m2 with at least ne clinically significant besity related disease such as diabetes mellitus, bstructive sleep apnea, crnary artery disease, r hypertensin fr which these cmplicatins r diseases are nt cntrlled by best practice medical management. PRIOR AUTHORIZATION Preauthrizatin is required fr BlueCHiP fr Medicare and recmmended fr all ther BCBSRI prducts. POLICY STATEMENT BlueCHiP fr Medicare The fllwing bariatric surgery prcedures may be cnsidered medically necessary fr the treatment f mrbid besity when the medical criteria belw are met Laparscpic gastric bypass using a Rux-en-Y anastmsis Laparscpic adjustable gastric banding Sleeve gastrectmy Gastric restrictive prcedure, with partial gastrectmy; pylrus-preserving dudenilestmy Open gastric bypass using a Rux-en-Y anastmsis Gastric restrictive prcedure, with gastric bypass with small intestine recnstructin Revisin, pen, f gastric restrictive prcedure fr mrbid besity, ther than adjustable gastric restrictive device The fllwing bariatric surgery prcedures are cnsidered nt medically necessary fr the treatment f mrbid besity in adults wh have failed weight lss by cnservative measures as there is insufficient peer reviewed scientific literature that demnstrates that the prcedure/service is effective.: Gastric bypass using a Billrth II type anastmsis (mini-gastric bypass) Bilipancreatic bypass withut dudenal switch Cmmercial Lng-limb gastric bypass (i.e., >150 cm) Endscpic prcedures (e.g., insertin f the StmaphyX device) as a primary bariatric prcedure r as a revisin prcedure (i.e., t treat weight gain after bariatric surgery t remedy large gastric stma r large gastric puches Gastric balln Intestinal bypass Bariatric surgery as a cure fr type 2 diabetes The fllwing bariatric surgery prcedures may be cnsidered medically necessary fr the treatment f mrbid besity when the medical criteria belw are met; Open gastric bypass using a Rux-en-Y anastmsis Laparscpic gastric bypass using a Rux-en-Y anastmsis 500 EXCHANGE STREET, PROVIDENCE, RI MEDICAL COVERAGE POLICY 1

2 Laparscpic adjustable gastric banding Sleeve gastrectmy Open r laparscpic bilipancreatic bypass (i.e., the Scpinar prcedure) with dudenal switch The fllwing bariatric surgery prcedures are cnsidered nt medically necessary fr the treatment f mrbid besity in adults wh have failed weight lss by cnservative measures: as there is insufficient peer reviewed scientific literature that demnstrates that the prcedure/service is effective. Vertical-banded gastrplasty Gastric bypass using a Billrth II type f anastmsis (mini-gastric bypass) Bilipancreatic bypass withut dudenal switch Lng-limb gastric bypass prcedure (i.e., >150 cm) Tw-stage bariatric surgery prcedures (e.g., sleeve gastrectmy as initial prcedure fllwed by bilipancreatic diversin at a later time) Endscpic prcedures (e.g., insertin f the StmaphyX device) as a primary bariatric prcedure r as a revisin prcedure, (i.e., t treat weight gain after bariatric surgery t remedy large gastric stma r large gastric puches Blue CHiP fr Medicare and Cmmercial Prducts Necessary revisin fr a gastric restrictive prcedure r remval f adjustable gastric band r subcutaneus prt are cvered and d nt require prir authrizatin. Adjustment f gastric band diameter via subcutaneus prt by injectin r aspiratin f saline is cvered but nt separately reimbursed fr all prducts MEDICAL CRITERIA Fr BlueCHiP fr Medicare Bariatric surgery prcedure is cnsidered medically necessary when all f the fllwing medical criteria are met: A bdy-mass index > 35, At least ne c-mrbidity related t besity, and Unsuccessful with medical treatment fr besity. Cmmercial Prducts: Adults (ages 18 and greater) Bariatric surgery is cnsidered medically necessary fr adults ages 18 years and ver when all f the fllwing medical criteria are met: BMI f greater than 40 kg/m r a BMI greater than 35 kg/m with at least ne significant cmrbidity (e.g., high bld pressure, diabetes, etc.); and; Active participatin in weight reductin prgrams fr at least 6 mnths with supprting dcumentatin f mnthly weight, dietary and exercise rutines. The attempts must be reviewed by the practitiner seeking apprval fr the surgical prcedure. N untreated metablic/endcrine abnrmalities Diagnsis f mrbid besity fr 2 years. Pre-perative nutritinal assessment and cunseling Pre-perative psychlgical assessment Dcumentatin that the member has nt smked in the previus 6 mnths N active substance abuse r treatment fr substance abuse in last 12 mnths Adlescents (under the age f 18) Bariatric surgery is cnsidered medically necessary fr adlescents under the age f 18 years when all f the fllwing medical criteria are met: BMI >40kg/m/m.2 with at least ne serius besity-related c-mrbidity that is prly cntrlled; r 500 EXCHANGE STREET, PROVIDENCE, RI MEDICAL COVERAGE POLICY 2

3 BMI f 50kg/m2 r greater with less severe c-mrbidities (e.g., high bld pressure, diabetes, etc.); AND Active participatin in a weight reductin prgrams fr at least 6 mnths with dcumentatin f mnthly weight, dietary and exercise rutines. The attempts must be reviewed by the practitiner seeking apprval fr the surgical prcedure. N untreated metablic/endcrine abnrmalities Diagnsis f mrbid besity fr 2 years Pre-perative nutritinal assessment & cunseling Pre-perative psychlgical assessment Dcumentatin that the member has nt smked in the previus 6 mnths N active substance abuse r treatment fr substance abuse in last 12 mnths Revisin f a primary bariatric prcedure that has failed due t dilatin f the gastric puch (dcumented by upper gastrintestinal examinatin r endscpy) is cnsidered medically necessary when all f the fllwing criteria are met; the initial prcedure was successful in inducing weight lss prir t puch dilatin and; the patient has been cmpliant with a prescribed nutritin and exercise prgram and; the patient still meets criteria (BMI) fr bariatric surgery. Repeat prcedures are medically necessary when all f the fllwing criteria belw are met; Meets all criteria fr initial prcedure Previus surgery at least 2 years prir t repeat surgery Weight lss frm initial surgery <50% f excess bdy weight at time f initial surgery Member cmplied with previusly prescribed prgram BACKGROUND Bariatric surgery is perfrmed fr the treatment f mrbid (clinically severe) besity. Mrbid besity is defined as a bdy mass index (*BMI) greater than 40 kg/m2 r a BMI greater than 35 kg/m2 with at least ne clinically significant besity-related disease such as diabetes mellitus, bstructive sleep apnea, crnary artery disease, r hypertensin fr which these cmplicatins r diseases are nt cntrlled by best practice medical management. *BMI is calculated by dividing weight (in kilgrams) by height (in meters) squared. T cnvert punds t kilgrams, multiply punds by T cnvert inches t meters, multiply inches by When cnservative measures fail, such as supervised diet, exercise and behavir mdificatin prgrams, patients may cnsider surgical appraches. A 1991 Natinal Institutes f Health (NIH) Cnsensus Cnference defined surgical candidates as thse patients with a BMI* f greater than 40 kg/m 2, r greater than 35 kg/m 2 in cnjunctin with severe c-mrbidities such as cardipulmnary cmplicatins r severe diabetes. Weight lss, durability f weight lss, perative and peri-perative cmplicatins, re-peratin rate, metablic side effects, and imprved health utcmes in terms f c-mrbidity reslutin are crucial t evaluatin f individual surgical prcedures. Recmmendatins frm the Natinal Institutes f Health stress the imprtance f a multidisciplinary apprach t bariatric surgery patients, including such ancillary services as nutritinal and psychlgical supprt. It is als recmmended that bariatric surgery prgrams prvide lifelng fllw-up fr treated patients. Types f Treatment 500 EXCHANGE STREET, PROVIDENCE, RI MEDICAL COVERAGE POLICY 3

4 Bariatric surgery falls int 2 general categries: Gastric-restrictive prcedures that create a small gastric puch, resulting in weight lss by prducing early satiety and thus decreasing dietary intake. They include Vertical-Banded Gastrplasty; Adjustable Gastric Banding; Open and laparscpic Gastric Bypass; Mini-gastric Bypass; and, Sleeve Gastrectmy. Malabsrptin prcedures, which prduce weight lss due t malabsrptin by altering the nrmal transit f ingested fd thrugh the intestinal tract. Malabsrptive prcedures include the fllwing surgeries: Bilipancreatic Bypass; Bilipancreatic Bypass with Dudenal Switch; Lng-Limb Gastric Bypass; and Laparscpic Malabsrptive prcedure. Blue CHiP fr Medicare The prcedures listed belw are cnsidered nt medically necessary because there is insufficient evidence in the published, peer-reviewed scientific literature t demnstrate its effectiveness. Medicare plicy is develped separately frm BCBSRI plicy. Medicare plicy incrprates cnsideratin f gvernmental regulatins frm CMS (Centers fr Medicare and Medicaid Services), such as natinal cverage determinatins r lcal cverage determinatins. In additin t benefit differences, CMS may reach different cnclusins regarding the scientific evidence than des BCBSRI. Medicare and BCBSRI plicies may differ. Hwever, BlueCHiP fr Medicare members must be ffered, at least, the same services as Medicare ffers. Open adjustable gastric banding; Open sleeve gastrectmy; Open and laparscpic vertical banding gastrplasty Gastric Balln Intestinal Bypass Cmmercial The prcedures listed belw are cnsidered nt medically necessary because there is insufficient evidence in the published, peer-reviewed scientific literature t demnstrate its effectiveness. Gastric bypass using a Billrth II type anastmsis (mini-gastric bypass) Bilipancreatic bypass withut dudenal switch Lng-limb gastric bypass (i.e., >150 cm) Endscpic prcedures (e.g., insertin f the StmaphyX device) as a primary bariatric prcedure r as a revisin prcedure (i.e., t treat weight gain after bariatric surgery t remedy large gastric stma r large gastric puches) Tw-stage bariatric surgery prcedures (e.g., sleeve gastrectmy as initial prcedure fllwed by bilipancreatic diversin at a later time) Gastric balln Intestinal bypass Bariatric surgery as a cure fr type 2 diabetes COVERAGE Benefits may vary between grups/cntracts. Please refer t the apprpriate Evidence f Cverage, Subscriber Agreement fr applicable surgical benefits. CODING The fllwing cdes are cvered fr BlueCHiP fr Medicare when medical criteria is met Laparscpic gastric restrictive prcedure; with gastric bypass and Rux-en-Y gastrenterscpy (rux limb 150cm r less) Laparscpic gastric restrictive prcedure; with gastric bypass and small intestine recnstructin t limit absrptin Laparscpic gastric restrictive prcedure; placement f adjustable band Laparscpic, surgical gastric restrictive bypass; lngitudinal gastrectmy (i.e., sleeve gastrectmy) 500 EXCHANGE STREET, PROVIDENCE, RI MEDICAL COVERAGE POLICY 4

5 43845 Gastric restrictive prcedure, with partial gastrectmy; pylrus-preserving dudenilestmy Gastric restrictive prcedure, with gastric bypass ; with shrt limb (less than 150 cm) Rux-n- Ygastrenterstmy Gastric restrictive prcedure, with gastric bypass fr mrbid besity with small intestine recnstructin t limit absrptin Revisin, pen, f gastric restrictive prcedure fr mrbid besity, ther than adjustable gastric restrictive device The fllwing cdes are cvered fr cmmercial prducts when medical criteria is met Laparscpic gastric restrictive prcedure; with gastric bypass and Rux-en-Y gastrenterscpy (rux limb 150cm r less) Laparscpic gastric restrictive prcedure; with gastric bypass and small intestine recnstructin t limit absrptin Laparscpic gastric restrictive prcedure; placement f adjustable band Laparscpic, surgical gastric restrictive bypass; lngitudinal gastrectmy (i.e., sleeve gastrectmy) Gastric restrictive prcedure, withut gastric bypass fr mrbid besity; vertical banded gastrplasty Gastric restrictive prcedure, with partial gastrectmy; pylrus-preserving dudenilestmy Gastric restrictive prcedure, with gastric bypass ; with shrt limb (less than 150 cm) Rux-n-Y gastrenterstmy Gastric restrictive prcedure, with gastric bypass fr mrbid besity with small intestine recnstructin t limit absrptin Revisin, pen, f gastric restrictive prcedure fr mrbid besity, ther than adjustable gastric restrictive device The fllwing cdes are cvered fr all BlueCHiP fr Medicare and Cmmercial prducts. Preauthrizatin is nt needed required Laparscpic gastric restrictive prcedure; revisin f adjustable gastric band cmpnent Laparscpic gastric restrictive prcedure; remval f adjustable gastric band cmpnent Laparscpic gastric restrictive prcedure; remval and replacement f adjustable gastric band cmpnent Laparscpic gastric restrictive prcedure; remval f adjustable gastric band and subcutaneus prt cmpnents Gastric restrictive prcedure, pen, revisin f subcutaneus prt nly Gastric restrictive prcedure, pen, remval f subcutaneus prt nly Gastric restrictive prcedure, pen, remval and replacement f subcutaneus prt nly The fllwing prcedure is nt separately reimbursed fr all BlueCHiP fr Medicare and Cmmercial prducts: S2083 Adjustment f gastric band diameter via subcutaneus prt by injectin r aspiratin f saline fr all prducts. RELATED POLICIES Nne PUBLISHED Prvider Dec, 2013 Prvider Jan, 2013 Prvider Sept, 2011 Prvider Apr, EXCHANGE STREET, PROVIDENCE, RI MEDICAL COVERAGE POLICY 5

6 Prvider Dec, 2009 Prvider Feb, 2009 Plicy Dec, 2007, Plicy Jul, 2007, Plicy Jun, 2006, Plicy Mar, 2001, REFERENCES Blue Crss and Blue Shield Assciatin. Medical Plicy Reference Manual: Bariatric Surgery. Plicy # Accessed 7/5/ The Centers fr Medicare and Medicaid Services. Natinal Cverage Determinatin (NCD) fr BARIATRIC SURGERY fr Treatment f Mrbid Obesity (100.1) Accessed 7/5/ The Centers fr Medicare and Medicaid Services. Decisin Mem fr Bariatric Surgery fr the Treatment f Mrbid Obesity (CAG-00250R2) June 27, Accessed 7/5/ y+(1st+recn)&bc=beaaaaaaeaaa&&frmdb=true Gastrintestinal Surgery fr Severe Obesity Weight Cntrl Infrmatin Netwrk. Natinal Institute f Diabetes and Kidney Diseases. Retrieved n August 21, 2007 frm NIDDK/NIH website: Bariatric Surgery. Vl. 294 N. 15, Octber 19, Jurnal f American Medical Assciatin. Retrieved n August 21, 2007 frm JAMA website: Natinal Institutes f Health. Cnsensus Develpment Cnference Statement.March 25-27, Vlume 9, Number 1. Gastrintestinal surgery fr severe besity. Retrieved n August 23, 2007 frm NIH website: Santry, H.P., Gillen, D.L., Lauderdale, D.S. (2005). Trends in bariatric surgery prcedures. Jurnal f American Medical Assciatin 2005, 294(15): e i 500 EXCHANGE STREET, PROVIDENCE, RI MEDICAL COVERAGE POLICY 6

7 CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS This medical plicy is made available t yu fr infrmatinal purpses nly. It is nt a guarantee f payment r a substitute fr yur medical judgment in the treatment f yur patients. Benefits and eligibility are determined by the member's subscriber agreement r member certificate and/r the emplyer agreement, and thse dcuments will supersede the prvisins f this medical plicy. Fr infrmatin n member-specific benefits, call the prvider call center. If yu prvide services t a member which are determined t nt be medically necessary (r in sme cases medically necessary services which are nn-cvered benefits), yu may nt charge the member fr the services unless yu have infrmed the member and they have agreed in writing in advance t cntinue with the treatment at their wn expense. Please refer t yur participatin agreement(s) fr the applicable prvisins. This plicy is current at the time f publicatin; hwever, medical practices, technlgy, and knwledge 500 EXCHANGE STREET, PROVIDENCE, RI MEDICAL COVERAGE POLICY 7

8 are cnstantly changing. BCBSRI reserves the right t review and revise this plicy fr any reasn and at any time, with r withut ntice. Blue Crss & Blue Shield f Rhde Island is an independent licensee f the Blue Crss and Blue Shield Assciatin. 500 EXCHANGE STREET, PROVIDENCE, RI MEDICAL COVERAGE POLICY 8