Bariatric Surgery MM /11/2001. HMO; PPO; QUEST Integration 09/26/2014 Section: Surgery Place(s) of Service: Outpatient; Inpatient

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1 Bariatric Surgery Policy Number: Original Effective Date: MM /11/2001 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 09/26/2014 Section: Surgery Place(s) of Service: Outpatient; Inpatient I. Description Surgery for morbid obesity, termed bariatric surgery, falls into two general categories: 1) gastricrestrictive procedures that create a small gastric pouch, resulting in weight loss by producing early satiety and thus decreasing dietary intake; and 2) malabsorptive procedures, which produce weight loss due to malabsorption by altering the normal transit of ingested food through the gastrointestinal tract. Some bariatric procedures may include both a restrictive and a malabsorptive component. HMSA is carefully monitoring the evolving literature and specialty society recommendations regarding the efficacy of lap band. Though we do not believe there is enough evidence at present to stop covering this procedure, HMSA believes providers should make it clear to members that current best practice distinctly favors gastric bypass and sleeve gastrectomy over placement of a lap band. Morbid obesity is defined as a body mass index (BMI) greater than 40 kg/m2 or a BMI greater than 35 kg/m2 with associated complications including, but not limited to, diabetes, hypertension, or obstructive sleep apnea. Morbid obesity results in a very high risk for weight-related complications, such as diabetes, hypertension, obstructive sleep apnea, and various types of cancers (for men: colon, rectum, and prostate; for women: breast, uterus, and ovaries), and a shortened life span. A 1991 National Institutes of Health (NIH) Consensus Conference defined surgical candidates as those patients with a BMI of greater than 40 kg/m 2, or greater than 35 kg/m 2 in conjunction with severe comorbidities such as cardiopulmonary complications or severe diabetes. Resolution (cure) or improvement of type 2 diabetes mellitus after bariatric surgery and observations that glycemic control may improve immediately after surgery, before a significant amount of weight is lost, have promoted interest in a surgical approach to treatment of type 2 diabetes. The various surgical procedures have different effects, and gastrointestinal rearrangement seems to confer additional anti-diabetic benefits independent of weight loss and caloric restriction. The precise mechanisms are not clear, and multiple mechanisms may be involved. Gastrointestinal peptides, glucagon-like peptide-1 (1GLP-1), glucose -dependent insulinotropic peptide (GIP), and peptide YY (PYY) are secreted in response to contact with unabsorbed nutrients and by vagally

2 Bariatric Surgery 2 mediated parasympathetic neural mechanisms. GLP-1 is secreted by the L cells of the distal ileum in response to ingested nutrients and acts on pancreatic islets to augment glucose-dependent insulin secretion. It also slows gastric emptying, which delays digestion, blunts postprandial glycemia, and acts on the central nervous system to induce satiety and decrease food intake. Other effects may improve insulin sensitivity. GIP acts on pancreatic beta cells to increase insulin secretion through the same mechanisms as GLP-1, although it is less potent. PYY is also secreted by the L cells of the distal intestine and increases satiety and delays gastric emptying. II. Criteria/Guidelines HMSA strongly recommends that prior to considering bariatric surgery, patients be evaluated by a multi-disciplinary clinical team (e.g., endocrinologists, psychiatrists, surgeons, dieticians, nurse practitioners) at a Medicare defined Center of Excellence or at a program that offers comprehensive weight management services. The program should contain the following services and be offered at the same location as the proposed surgical procedure to insure continuity of care: Nutrition counseling Weight-loss program Exercise guidance and support Education about lifestyle changes Preparation and follow up for surgery Support groups for patients before and after surgery A. Surgery for morbid obesity is covered (subject to Limitations/Exclusions and Administrative Guidelines) for members when the following criteria are met: 1. The patient is morbidly obese, defined as either of the following: a. Persistent and uncontrollable weight gain that constitutes a present or potential threat to life; i. Weight that is at least 100 pounds over or twice the ideal weight as described in the Metropolitan Life tables; or ii. A BMI greater than 40 kg/m²; or b. BMI of between 35 and 40 kg/m² with one of the following high-risk comorbidities: i. Severe sleep apnea (defined as repeated hypoxia with oxygen saturation less than 80% on sleep study; or documented pulmonary hypertension on echocardiogram or right heart catheterization; or sleep apnea induced right heart failure requiring hospitalization). ii. Pickwickian syndrome iii. Obesity-related cardiomyopathy iv. Type II diabetes mellitus with evaluation and recommendation for surgery by a multi-disciplinary team with expertise in weight, metabolic, and diabetic management and which is part of a comprehensive weight management program associated with the facility where the surgery will be performed. c. BMI of between 30 and 34.9 kg/m 2 with type II diabetes Type II diabetes mellitus with evaluation and recommendation for roux-en-y gastric bypass surgery by a multi-disciplinary team with expertise in weight, metabolic, and diabetic management and which is part of a comprehensive weight management

3 Bariatric Surgery 3 program associated with the facility where the surgery will be performed. For this category of patient, only Roux-en-Y gastric bypass is covered as the evidence has shown compelling benefit specifically with this particular operation, and not the other alternatives. 2. The surgery is intended to achieve one of two results: a. Alteration of the mechanics of food absorption; or b. Alteration in the volume of food ingested. 3. There is documentation that the patient's efforts to lose weight have not been successful. B. Surgery for morbid obesity in adolescents is covered (subject to Limitations/Exclusions and Administrative Guidelines) when the member meets the same weight-based criteria used for adults but greater consideration will be given to psychosocial and informed consent issues. All devices must be used in accordance with FDA-approved indications. C. Revisions, replacements, and re-dos of bariatric procedures are covered (subject to Limitations/Exclusions and Administrative Guidelines) if the patient met policy criteria at the time of the initial procedure, and there is documentation of a medically significant complication or failure. D. Bariatric surgery is covered only if the patient meets the criteria outlined above and when: 1. The facility is located in the state of Hawaii, has a contract with HMSA to perform bariatric surgery and has a comprehensive weight management program; or 2. The facility is an approved Blues Distinction Center for bariatric surgery with an agreement for continuity of care in the state where the member primarily resides. III. Limitations/Exclusions A. Lap band procedures must be performed in the outpatient setting unless the physician is recommending the procedure be done in an inpatient setting. When requesting precertification, the physician should outline concerns about the member's comorbidities, complex problems, age considerations, etc. B. Polysomnography performed as part of the routine evaluation of patients prior to bariatric surgery is not covered as it is not known to be effective in improving health outcomes. Please see Polysomnography Sleep Studies policy for coverage criteria. C. Esophagogastroduodenoscopy (EGD) performed as part of the routine evaluation of patients prior to bariatric surgery is not covered as it is not known to be effective in improving health outcomes. IV. Administrative Guidelines Precertification is required. To precertify for procedure and place of treatment, please complete HMSA's Precertification Request and mail or fax the form as indicated. Click for Metropolitan Life Tables

4 Bariatric Surgery 4 CPT Codes Description Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Rouxen-Y gastroenterostomy (roux limb 150 cm or less) with gastric bypass and small intestine reconstruction to limit absorption Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g. gastric band and subcutaneous port components) revision of adjustable gastric restrictive device component only removal of adjustable gastric restrictive device component only removal and replacement of adjustable gastric restrictive device component only removal of adjustable gastric restrictive device and subcutaneous port components longitudinal gastrectomy (i.e., sleeve gastrectomy) Gastric restrictive procedure, without gastric bypass for morbid obesity; verticalbanded gastroplasty other than vertical-banded gastroplasty Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy with small intestine reconstruction to limit absorption Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) Gastric restrictive procedure, open; revision of subcutaneous port component only removal of subcutaneous port component only removal and replacement of subcutaneous port component only Unlisted procedure, stomach HCPCS S2083 Description Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline

5 Bariatric Surgery 5 ICD-9 Procedure Codes Description Endoscopic excision or destruction of lesion or tissue of stomach 43.7 Partial gastrectomy with anastomosis to jejunum (biliopancreatic diversion) Laparoscopic vertical (sleeve) gastrectomy Other partial gastrectomy (biliopancreatic diversion with duodenal switch and sleeve gastrectomy) High gastric bypass Laparoscopic vertical (sleeve) gastrectomy Other gastroenterostomy without gastrectomy 44.5 Revision of gastric anastomosis Laparoscopic gastroplasty Other repair of stomach Laparoscopic gastric restrictive procedure (adjustable gastric band and port) code range ICD-10 codes are provided for your information. These will not become effective until October 1, ICD-10 Procedure Codes 0D160ZA 0D164ZA 0D168ZA 0DB60ZZ 0DB63ZZ 0DB64ZZ 0DB67ZZ 0DB68ZZ 0DB64Z3 0DB60Z3 0DB60ZZ Description Bypass Stomach to Jejunum, Open Bypass Stomach to Jejunum, Percutaneous Endoscopic Bypass Stomach to Jejunum, Via Natural or Excision of Stomach, Open Excision of Stomach, Percutaneous Excision of Stomach, Percutaneous Endoscopic Excision of Stomach, Via Natural or Artificial Opening Excision of Stomach, Via Natural or Excision of Stomach, Percutaneous Endoscopic, Vertical Excision of Stomach, Open, Vertical Excision of Stomach, Open

6 Bariatric Surgery 6 0DB63Z3 0DB63ZZ 0DB67Z3 0DB67ZZ 0DB68Z3 0D1607A 0D160JA 0D160KA 0D160ZA 0D1687A 0D168JA 0D168KA 0D168ZA 0D D1647A 0D1647B 0D1647L 0D164J9 0D164JA 0D164JB 0D164JL 0D164K9 Excision of Stomach, Percutaneous, Vertical Excision of Stomach, Percutaneous Excision of Stomach, Via Natural or Artificial Opening, Vertical Excision of Stomach, Via Natural or Artificial Opening Excision of Stomach, Via Natural or, Vertical Bypass Stomach to Jejunum with Autologous Tissue Substitute, Open Bypass Stomach to Jejunum with Synthetic Substitute, Open Bypass Stomach to Jejunum with Nonautologous Tissue Substitute, Open Bypass Stomach to Jejunum, Open Bypass Stomach to Jejunum with Autologous Tissue Substitute, Via Natural or Bypass Stomach to Jejunum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic Bypass Stomach to Jejunum with Nonautologous Tissue Substitute, Via Natural or Bypass Stomach to Jejunum, Via Natural or Bypass Stomach to Duodenum with Autologous Tissue Substitute, Percutaneous Endoscopic Bypass Stomach to Jejunum with Autologous Tissue Substitute, Percutaneous Endoscopic Bypass Stomach to Ileum with Autologous Tissue Substitute, Percutaneous Endoscopic Bypass Stomach to Transverse Colon with Autologous Tissue Substitute, Percutaneous Endoscopic Bypass Stomach to Duodenum with Synthetic Substitute, Percutaneous Endoscopic Bypass Stomach to Jejunum with Synthetic Substitute, Percutaneous Endoscopic Bypass Stomach to Ileum with Synthetic Substitute, Percutaneous Endoscopic Bypass Stomach to Transverse Colon with Synthetic Substitute, Percutaneous Endoscopic Bypass Stomach to Duodenum with Nonautologous Tissue Substitute, Percutaneous Endoscopic

7 Bariatric Surgery 7 0D164KA 0D164KB 0D164KL 0D164Z9 0D164ZA 0D164ZB 0D164ZL 0D D1607A 0D1607B 0D1607L 0D160J9 0D160JA 0D160JB 0D160JL 0D160K9 0D160KA 0D160KB 0D160KL 0D160Z9 0D160ZA 0D160ZB 0D160ZL 0D16879 Bypass Stomach to Jejunum with Nonautologous Tissue Substitute, Percutaneous Endoscopic Bypass Stomach to Ileum with Nonautologous Tissue Substitute, Percutaneous Endoscopic Bypass Stomach to Transverse Colon with Nonautologous Tissue Substitute, Percutaneous Endoscopic Bypass Stomach to Duodenum, Percutaneous Endoscopic Bypass Stomach to Jejunum, Percutaneous Endoscopic Bypass Stomach to Ileum, Percutaneous Endoscopic Bypass Stomach to Transverse Colon, Percutaneous Endoscopic Bypass Stomach to Duodenum with Autologous Tissue Substitute, Open Bypass Stomach to Jejunum with Autologous Tissue Substitute, Open Bypass Stomach to Ileum with Autologous Tissue Substitute, Open Bypass Stomach to Transverse Colon with Autologous Tissue Substitute, Open Bypass Stomach to Duodenum with Synthetic Substitute, Open Bypass Stomach to Jejunum with Synthetic Substitute, Open Bypass Stomach to Ileum with Synthetic Substitute, Open Bypass Stomach to Transverse Colon with Synthetic Substitute, Open Bypass Stomach to Duodenum with Nonautologous Tissue Substitute, Open Bypass Stomach to Jejunum with Nonautologous Tissue Substitute, Open Bypass Stomach to Ileum with Nonautologous Tissue Substitute, Open Bypass Stomach to Transverse Colon with Nonautologous Tissue Substitute, Open Bypass Stomach to Duodenum, Open Bypass Stomach to Jejunum, Open Bypass Stomach to Ileum, Open Bypass Stomach to Transverse Colon, Open Bypass Stomach to Duodenum with Autologous Tissue Substitute, Via Natural or

8 Bariatric Surgery 8 0D1687A 0D1687B 0D1687L 0D168J9 0D168JA 0D168JB 0D168JL 0D168K9 0D168KA 0D168KB 0D168KL 0D168Z9 0D168ZA 0D168ZB 0D168ZL 0DQ60ZZ 0DQ63ZZ 0DQ64ZZ 0DQ67ZZ 0DQ68ZZ 0DQ64ZZ 0DV64CZ Bypass Stomach to Jejunum with Autologous Tissue Substitute, Via Natural or Bypass Stomach to Ileum with Autologous Tissue Substitute, Via Natural or Bypass Stomach to Transverse Colon with Autologous Tissue Substitute, Via Natural or Bypass Stomach to Duodenum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic Bypass Stomach to Jejunum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic Bypass Stomach to Ileum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic Bypass Stomach to Transverse Colon with Synthetic Substitute, Via Natural or Bypass Stomach to Duodenum with Nonautologous Tissue Substitute, Via Natural or Bypass Stomach to Jejunum with Nonautologous Tissue Substitute, Via Natural or Bypass Stomach to Ileum with Nonautologous Tissue Substitute, Via Natural or Bypass Stomach to Transverse Colon with Nonautologous Tissue Substitute, Via Natural or Bypass Stomach to Duodenum, Via Natural or Bypass Stomach to Jejunum, Via Natural or Bypass Stomach to Ileum, Via Natural or Bypass Stomach to Transverse Colon, Via Natural or Repair Stomach, Open Repair Stomach, Percutaneous Repair Stomach, Percutaneous Endoscopic Repair Stomach, Via Natural or Artificial Opening Repair Stomach, Via Natural or Repair Stomach, Percutaneous Endoscopic Restriction of Stomach with Extraluminal Device, Percutaneous Endoscopic

9 Bariatric Surgery 9 0D760DZ 0D760ZZ 0D763DZ 0D763ZZ 0D764DZ 0D764ZZ 0D767DZ 0D767ZZ 0D768DZ 0D768ZZ 0DF60ZZ 0DF63ZZ 0DF64ZZ 0DF67ZZ 0DF68ZZ 0DM60ZZ 0DM64ZZ 0DN60ZZ 0DN63ZZ 0DN64ZZ 0DN67ZZ 0DN68ZZ 0DQ60ZZ 0DQ63ZZ 0DQ67ZZ 0DQ68ZZ 0DU607Z 0DU60JZ 0DU60KZ 0DU647Z Dilation of Stomach with Intraluminal Device, Open Dilation of Stomach, Open Dilation of Stomach with Intraluminal Device, Percutaneous Dilation of Stomach, Percutaneous Dilation of Stomach with Intraluminal Device, Percutaneous Endoscopic Dilation of Stomach, Percutaneous Endoscopic Dilation of Stomach with Intraluminal Device, Via Natural or Artificial Opening Dilation of Stomach, Via Natural or Artificial Opening Dilation of Stomach with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Stomach, Via Natural or Fragmentation in Stomach, Open Fragmentation in Stomach, Percutaneous Fragmentation in Stomach, Percutaneous Endoscopic Fragmentation in Stomach, Via Natural or Artificial Opening Fragmentation in Stomach, Via Natural or Reattachment of Stomach, Open Reattachment of Stomach, Percutaneous Endoscopic Release Stomach, Open Release Stomach, Percutaneous Release Stomach, Percutaneous Endoscopic Release Stomach, Via Natural or Artificial Opening Release Stomach, Via Natural or Repair Stomach, Open Repair Stomach, Percutaneous Repair Stomach, Via Natural or Artificial Opening Repair Stomach, Via Natural or Supplement Stomach with Autologous Tissue Substitute, Open Supplement Stomach with Synthetic Substitute, Open Supplement Stomach with Nonautologous Tissue Substitute, Open Supplement Stomach with Autologous Tissue Substitute, Percutaneous

10 Bariatric Surgery 10 0DU64JZ 0DU64KZ 0DU677Z 0DU67JZ 0DU67KZ 0DU687Z 0DU68JZ 0DU68KZ 0DV60CZ 0DV60DZ 0DV60ZZ 0DV63CZ 0DV63DZ 0DV63ZZ 0DV64DZ 0DV64ZZ 0DV67ZZ 0DV68ZZ 0DV64CZ 0DW643Z 0DW64CZ 0DP643Z 0DP64CZ Endoscopic Supplement Stomach with Synthetic Substitute, Percutaneous Endoscopic Supplement Stomach with Nonautologous Tissue Substitute, Percutaneous Endoscopic Supplement Stomach with Autologous Tissue Substitute, Via Natural or Artificial Opening Supplement Stomach with Synthetic Substitute, Via Natural or Artificial Opening Supplement Stomach with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Supplement Stomach with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic Supplement Stomach with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic Supplement Stomach with Nonautologous Tissue Substitute, Via Natural or Restriction of Stomach with Extraluminal Device, Open Restriction of Stomach with Intraluminal Device, Open Restriction of Stomach, Open Restriction of Stomach with Extraluminal Device, Percutaneous Restriction of Stomach with Intraluminal Device, Percutaneous Restriction of Stomach, Percutaneous Restriction of Stomach with Intraluminal Device, Percutaneous Endoscopic Restriction of Stomach, Percutaneous Endoscopic Restriction of Stomach, Via Natural or Artificial Opening Restriction of Stomach, Via Natural or Restriction of Stomach with Extraluminal Device, Percutaneous Endoscopic Revision of Infusion Device in Stomach, Percutaneous Endoscopic Revision of Extraluminal Device in Stomach, Percutaneous Endoscopic Removal of Infusion Device from Stomach, Percutaneous Endoscopic Removal of Extraluminal Device from Stomach, Percutaneous Endoscopic

11 Bariatric Surgery 11 3E0G3GC Introduction of Other Therapeutic Substance into Upper GI, Percutaneous V. Important Reminder The purpose of this Medical Policy is to provide a guide to coverage. This Medical Policy is not intended to dictate to providers how to practice medicine. Nothing in this Medical Policy is intended to discourage or prohibit providing other medical advice or treatment deemed appropriate by the treating physician. Benefit determinations are subject to applicable member contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control. This Medical Policy has been developed through consideration of the medical necessity criteria under Hawaii s Patients Bill of Rights and Responsibilities Act (Hawaii Revised Statutes 432E-1.4), generally accepted standards of medical practice and review of medical literature and government approval status. HMSA has determined that services not covered under this Medical Policy will not be medically necessary under Hawaii law in most cases. If a treating physician disagrees with HMSA s determination as to medical necessity in a given case, the physician may request that HMSA reconsider the application of the medical necessity criteria to the case at issue in light of any supporting documentation. VI. References 1. American Gastroenterological Association. Medical position statement on obesity. Gastroenterology. Sept. 2002; 123(3): American Society for Metabolic and Bariatric Surgery (ASMBS) 29th Annual Meeting: Abstract PL 103. Presented June 20, American Society for Metabolic and Bariatric Surgery. Statement/Guidelines: Bariatric surgery in class 1 obesity (body mass index 30 35kg/m 2 ). Surgery for obesity and Related Diseases 9 (2013) e1 e American Society for Metabolic and Bariatric Surgery. Updated position statement on sleeve gastrectomy as a bariatric procedure. Draft Revised; October 14, HMSA Guide to Benefits, Ikramuddin S, Korner J, Lee WJ et al. Roux-en-Y gastric bypass vs. intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. JAMA 2013; 309(21): Medical Policy Reference Manual. Blue Cross and Blue Shield Association. Bariatric Surgery, Policy # ; September 2013 draft. Blue Cross Blue Shield Association. Technology Evaluation Committee. Laparoscopic Adjustable Gastric Banding for Morbid Obesity. February Blue Cross and Blue Shield Association. Technology Evaluation Committee. Bariatric Surgery in Patients with Diabetes and Body Mass Index Less Than 35 kg/m NIH Consensus Development Conference Statement. Gastrointestinal surgery for morbid obesity. March 1991; 9:1-20.

12 Bariatric Surgery The American Society for Metabolic and Bariatric Surgery. Updated position statement on sleeve gastrectomy as a bariatric procedure. Revised Surgery for Obesity and Related Diseases Jan-Feb 6(1):1-5. Position Statement.