Bariatric Surgery And Procedures - Cigna
Medical Coverage PolicyEffective Date .12/15/2020Next Review Date. 7/15/2021Coverage Policy Number . 0051Bariatric Surgery and ProceduresTable of ContentsRelated Coverage ResourcesOverview . 2Coverage Policy . 2Adults . 2Bariatric Surgery Procedures (Adults) . 3Reoperation and Revisional Bariatric Surgery(Adults) . 4Adolescents . 5Bariatric Surgery Procedures (Adolescents) . 5Reoperation and Revisional Bariatric Surgery(Adolescents). 6Adults and Adolescents. 6Bariatric Surgery for the Treatment of DiabetesMellitus . 6Cholecystectomy, Liver Biopsy, Herniorrhaphy,Prophylactic Vena Cava Filter Placement, orUpper Endoscopy . 6General Background . 7Bariatric Surgery Procedures . 13Other Bariatric Surgical Procedures . 18Reoperation/Revisional Bariatric Surgery . 44Bariatric Surgery for the Treatment of DiabetesMellitus (DM) . 45Cholecystectomy, Liver Biopsy, Herniorrhaphy,Prophylactic Vena Cava Filter Placement, orUpper Endoscopy . 50Medicare Coverage Determinations . 57Coding/Billing Information. 57References . 62Gastric Pacing/Gastric Electrical Stimulation (GES)Obstructive Sleep Apnea Treatment ServicesPanniculectomy and AbdominoplastySleep Testing ServicesVagus Nerve Stimulation (VNS)INSTRUCTIONS FOR USEThe following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines ofbusiness only provide utilization review services to clients and do not make coverage determinations. References to standard benefit planlanguage and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpretingcertain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document[Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] maydiffer significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plandocument may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefitplan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coveragemandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specificinstance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicablelaws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particularsituation. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations forPage 1 of 84Medical Coverage Policy: 0051
treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to supportmedical necessity and other coverage determinations.OverviewThis Coverage Policy addresses bariatric surgery and procedures for the treatment of morbid obesity.Coverage PolicyCoverage for bariatric surgery or revision of a bariatric surgery procedure varies across plans and maybe governed by state mandates. Refer to the customer’s benefit plan document for coverage details.This coverage policy statement is organized as follows:1) Criteria that applies to Adults only2) Criteria that applies to Adolescents only3) Criteria that applies to Adults and AdolescentsAdultsBariatric surgery for the treatment of morbid obesity in an adult (age 18 years) using a coveredprocedure outlined below is considered medically necessary when ALL of the following criteria are met: EITHER of the following: BMI (Body Mass Index) 40BMI (Body Mass Index) 35–39.9 with at least one clinically significant obesity-related comorbidity,including but not limited to the following:ooooooooo mechanical arthropathy in a weight-bearing joint (symptomatic degenerative joint disease in aweight bearing joint)diabetes mellituspoorly controlled hypertension (systolic blood pressure at least 140 mm Hg or diastolic bloodpressure 90 mm Hg or greater, despite optimal medical management)hyperlipidemiacoronary artery diseaselower extremity lymphatic or venous obstructionobstructive sleep apneapulmonary hypertensionevidence of fatty liver disease (i.e., nonalcoholic fatty liver disease [NAFLD] or nonalcoholicsteatohepatitis [NASH])A statement from a physician/physician assistant/nurse practitioner/licensed mental healthprovider/registered dietician that the individual has failed previous attempts to achieve and maintainweight loss by medical management.A thorough multidisciplinary evaluation within the previous six months which includes ALL of thefollowing: a description of the proposed procedure(s)a recommendation for bariatric surgery from a physician/ physician assistant/nurse practitioner otherthan the requesting surgeon or associated staffunequivocal clearance for bariatric surgery by a mental health providera nutritional evaluation by a physician, physician assistant, nurse practitioner or registered dieticianPage 2 of 84Medical Coverage Policy: 0051
Bariatric Surgery Procedures (Adults)When the specific medical necessity criteria noted above for bariatric surgery for an adult have beenmet, ANY of the following open or laparoscopic bariatric surgery procedures for the treatment of morbidobesity is considered medically necessary:ProcedureVertical band gastroplastyAdjustable silicone gastric banding (e.g., LAPBAND , REALIZE )Sleeve gastrectomy as a stand-alone orstaged procedureRoux-en-Y gastric bypass(roux limb less than 150 cm)Roux-en-Y gastric bypass(roux limb greater than 150 cm)Biliopancreatic Diversion with DuodenalSwitch (BPD/DS)Billiopancreatic Diversion (BPD) without DSOpen CPT Codes4384243843Laparoscopic CPT 43659, 447994363343659Adjustment of a silicone gastric banding is considered medically necessary to control the rate of weightloss and/or treat symptoms secondary to gastric restriction following a medically necessary adjustablesilicone gastric banding procedure.The following bariatric surgery procedures for the treatment of morbid obesity, when performed alone orin conjunction with another bariatric surgery procedure are considered experimental, investigational orunproven:ProcedureBand over bypassBand over sleeveFobi-Pouch (limiting proximal gastric pouch)Gastric electrical stimulation (GES) or gastric pacingGastroplasty (stomach stapling)Intestinal bypass (jejunoileal bypass)Intragastric balloon (e.g., Orbera , ReShape , Obalon)Laparoscopic greater curvature plicationLoop gastric bypassMini-gastric bypassNatural Orifice Transluminal Endoscopic Surgery(NOTES)/endoscopic oral-assisted bariatric surgeryprocedures, including but not limited to the following: restorative obesity surgery, endoluminal(ROSE) StomaphyX , duodenojejunal bypass liner (e.g.,Endobarrier ) transoral gastroplasty (e.g., TOGA ) endoscopic closure devices (e.g., ApolloOverStitch )Roux-en-Y gastric bypass combined with simultaneousgastric bandingPage 3 of 84Medical Coverage Policy: 0051CPT Code(s)43770, 43843, 4399943770, 43843, 4399943659, 43843, 4399964590 and 43881OR64590 and 4364743659, 4384344238, 44799439994365943659, 4384343659, 4384343289, 4349943644 or 43645 and 43770OR
Single-anastomosis duodenal switch (DS)Stomach aspiration therapy (e.g., AspireAssist )Vagus nerve blocking (e.g., Maestro )Vagus nerve stimulation43846 or 43847 and 43843 or 4399943659, 43999, 4479943659, 439990312T, 0313T, 0316T, 0317T61885 and 64568OR61885 and 64553Reoperation and Revisional Bariatric Surgery (Adults)Replacement of an adjustable silicone gastric band or separate or concurrent band removal andconversion to a second bariatric surgical procedure is considered medically necessary if there isevidence of band slippage or band component malfunction and the faulty component cannot berepaired.Gastric band removal is considered medically necessary for gastrointestinal symptomology (e.g.,persistent nausea and/or vomiting, gastroesophageal reflux) with or without imaging evidence ofobstruction.The following procedures are considered medically necessary when the individual develops a majorcomplication from a primary bariatric surgery procedure (e.g., stricture, obstruction, erosion, gastricprolapse, ulceration, fistula formation, esophageal dilatation, gastroesophageal reflux disease refractoryto medical therapy): surgical repair or reversal (i.e., takedown)conversion to a medically necessary bariatric surgery procedureRevision of a previous bariatric surgical procedure or conversion to another medically necessaryprocedure for an adult due to inadequate weight loss is considered medically necessary when ALL ofthe following are met: The requested procedure includes ANY of the following:ProcedureVertical band gastroplastyAdjustable silicone gastric banding (e.g.,LAP-BAND , REALIZE )Sleeve gastrectomy as a stand-alone orstaged procedureRoux-en-Y gastric bypass(roux limb less than 150 cm)Roux-en-Y gastric bypass(roux limb greater than 150 cm)Biliopancreatic Diversion with DuodenalSwitch (BPD/DS)Billiopancreatic Diversion (BPD) without DSRevision of gastrojejunal anastomosis(gastrojejunostomy) Open CPT Codes4384243843Laparoscopic CPT 43659, 4479943633438604365943659Due to a technical failure† of the original bariatric surgical procedure (e.g., pouch dilatation, unsuccessfulband adjustments), the individual has failed to achieve adequate weight loss, which is defined as failureto lose at least 50% of excess body weight or failure to achieve body weight to within 30% of ideal bodyweight at least two years following the original surgery.Page 4 of 84Medical Coverage Policy: 0051
In the absence of a technical failure or major complication, individuals with weight loss failure twoyears following a primary bariatric surgery procedure must meet the initial medical necessity criteriafor surgery.NOTE: Inadequate weight loss due to individual noncompliance with postoperative nutrition andexercise recommendations is not a medically necessary indication for revision orconversion surgery.†Surgical reversal (i.e., takedown), revision of a previous bariatric surgical procedure or conversion toanother bariatric surgical procedure for ANY other indication is considered not medically necessary.AdolescentsBariatric surgery for the treatment of morbid obesity in an adolescent (age 11–17 years) is consideredmedically necessary using a covered procedure outlined below when ALL of the following criteria aremet: The individual has evidence of EITHER of the following: BMI (Body Mass Index) 40 BMI (Body Mass Index) 35–39.9 with at least one clinically significant obesity-related comorbidity,including but not limited to the following:ooooooo coronary artery diseasediabetes mellitusidiopathic intracranial hypertensionpoorly controlled hypertension (systolic blood pressure at least 140 mm Hg or diastolic bloodpressure 90 mm Hg or greater, despite optimal medical management)obstructive sleep apneagastroesophageal refluxnonalcoholic steatohepatitis [NASH])A statement from a physician/physician assistant/nurse practitioner/licensed mental healthprovider/registered dietician that the individual has failed previous attempts to achieve and maintainweight loss by medical management.A thorough multidisciplinary evaluation within the previous six months which includes ALL of thefollowing: a recommendation for bariatric surgery from a physician/physician assistant/nurse practitioner otherthan the requesting surgeon or associated staffunequivocal clearance for bariatric surgery by a mental health providera nutritional evaluation by a physician, physician assistant, nurse practitioner or registered dieticianBariatric Surgery Procedures (Adolescents)When the specific medical necessity criteria noted above for bariatric surgery for an adolescent havebeen met, ANY of the following open or laparoscopic bariatric surgery procedures for the treatment ofmorbid obesity is considered medically necessary:ProcedureSleeve gastrectomyRoux-en-Y gastric bypass(roux limb less than 150 CM)Roux-en-Y gastric bypass(roux limb greater than 150 CM)Page 5 of 84Medical Coverage Policy: 0051Open CPT Codes4384343846Laparoscopic CPT Codes43775436444384743645
All other bariatric surgery procedures for the treatment of morbid obesity in an adolescent areconsidered experimental, investigational or unproven.The following procedures are considered medically necessary when the adolescent develops a majorcomplication from a primary bariatric surgery procedure (e.g., stricture, obstruction, erosion, gastricprolapse, ulceration, fistula formation, esophageal dilatation): surgical repairconversion to a medically necessary bariatric surgery procedure (i.e., Roux-en-Y or sleeve gastrectomy)Reoperation and Revisional Bariatric Surgery (Adolescents)Revision of a previous bariatric surgical procedure or conversion to another medically necessaryprocedure due to inadequate weight loss is considered medically necessary when ALL of the followingare met: The requested procedure includes ANY of the following:ProcedureSleeve gastrectomyRoux-en-Y gastric bypass(roux limb less than 150 CM)Roux-en-Y gastric bypass(roux limb greater than 150 CM)Revision of gastrojejunal anastomosis(gastrojejunostomy) Open CPT Codes4384343846Laparoscopic CPT Codes437754364443847436454386043659Due to a technical failure† of the original bariatric surgical procedure (e.g., pouch dilatation) the individualhas failed to achieve adequate weight loss, which is defined as failure to lose at least 50% of excessbody weight or failure to achieve body weight to within 30% of ideal body weight at least two yearsfollowing the original surgery.†In the absence of a technical failure or major complication, individuals with weight loss failure twoyears following a primary bariatric surgery procedure must meet the initial medical necessity criteriafor surgery.NOTE: Inadequate weight loss due to individual noncompliance with postoperative nutrition andexercise recommendations is not a medically necessary indication for revision orconversion surgery.Surgical reversal (i.e., takedown), revision of a previous bariatric surgical procedure or conversion toanother bariatric surgical procedure for ANY other indication is considered not medically necessary.Adults and AdolescentsBariatric Surgery for the Treatment of Diabetes MellitusA bariatric surgical procedure performed solely for the treatment of diabetes mellitus with a BMI 35 isconsidered experimental, investigational or unproven.Cholecystectomy, Liver Biopsy, Herniorrhaphy, Prophylactic Vena Cava Filter Placement, or UpperEndoscopyPage 6 of 84Medical Coverage Policy: 0051
Prophylactic vena cava filter placement at the time of bariatric surgery is considered medicallynecessary for an individual who is considered to be high risk for venous thromboembolism (VTE) due toa history of ANY of the following conditions: deep vein thrombosis (DVT)hypercoagulable stateincreased right-sided heart pressurespulmonary embolus (PE)The following procedures performed in conjunction with a bariatric surgery are considered not medicallynecessary: cholecystectomy in the absence of signs or symptoms of gallbladder diseaseliver biopsy in the absence of signs or symptoms of liver disease (e.g., elevated liver enzymes,enlarged liver, abnormal intraoperative findings)routine vena cava filter placement for individuals not at high risk for venous thromboembolism (VTE)When performed as part of a bariatric surgery procedure, simple suture repair (i.e., without mesh) of adiaphragmatic defect for a hiatal hernia is considered to be integral to the bariatric procedure and notseparately reimbursable.Upper gastrointestinal endoscopy performed concurrent with a bariatric surgery procedure to confirm asurgical anastomosis or to establish anatomical landmarks is considered to be an integral part of themore comprehensive surgical procedure and not separately reimbursable.General BackgroundObesity and overweight are defined clinically using the body mass index (BMI). BMI is an objective measurementand is currently considered the most reproducible measurement of total body fat. In adults, excess body weight(EBW) is defined as the amount of weight that is in excess of the ideal body weight (IBW), or a BMI 25 kg/m2The National Heart, Lung and Blood Institute (NHLBI) (1998) clinical guidelines recommended that the BMIshould be used to classify overweight and obesity and to estimate relative risk for disease compared to normalweight The NHLBI (1998) defined the following classifications based on BMI:ClassificationBMIUnderweight 18.5 kg/m2Normal weight18.5–24.9 kg/m2Overweight25.0–29.9 kg/m2Obesity (Class 1)30.0–34.9 kg/m2Obesity (Class 2)35.0–39.9 kg/m2Extreme Obesity (Class 3) 40 kg/m2BMI is a direct calculation based on height and weight, regardless of gender:BMI Page 7 of 84Medical Coverage Policy: 0051weight (kg )height (m 2 ) weight (lb) x 7032 height (in) OR
Clinically severe or morbid obesity is defined as a BMI 40 or a BMI of 35–39.9 with comorbid conditions.Another group of individuals who have been identified are the super-obese. Super-obesity has been defined inthe literature as a BMI 50. Comorbidities of morbid obesity that may be considered include any of the following: mechanical arthropathy (weight-related degenerative joint disease)type 2 diabetesclinically unmanageable hypertension (systolic blood pressure at least 140 mm Hg or diastolic bloodpressure 90 mm Hg or greater, or if individual is taking antihypertensive agents)hyperlipidemiacoronary artery diseaselower extremity lymphatic or venous obstructionsevere obstructive sleep apneaobesity-related pulmonary hypertensionOther severe obesity-related co-morbidities including obesity-hypoventilation syndrome (OHS), Pickwickiansyndrome (a combination of obstructive sleep apnea [OSA] and OHS), nonalcoholic fatty liver disease (NAFLD)or nonalcoholic steatohepatitis (NASH), pseudotumor cerebri, gastroesophageal reflux disease (GERD), asthma,venous stasis disease, severe urinary incontinence, or considerably impaired quality of life, may also beconsidered for bariatric surgical intervention (Mechanick, et al., 2013).Strategies for Weight LossTreatment of obesity is generally described as a two-part process: 1) assessment, including BMI measurementand risk factor identification; and 2) treatment/management. Obesity management includes primary weight loss,prevention of weight regain and the management of associated risk. During the assessment phase, the individualneeds to be prepared for the comprehensive nature of the program, including realistic timelines and goals.Gener
This Coverage Policy addresses bariatric surgery and procedures for the treatment of morbid obesity. Coverage Policy . Coverage for bariatric surgery or revision of a bariatric surgery procedure varies across plans and may be governed by state mandates. Refer to t
Oct 18, 2017 · Silver: Cigna Connect 2500, Cigna US-TN Connect 3500, Cigna Connect 3000 Tri-Cities: Bronze: Cigna Connect 7000, Cigna Connect 5250 Silver: Cigna Connect 4750, Cigna Connect 4500 Bronze: Cigna US-TN Connect 6650, Cigna Connect HSA 5000, Cigna Connect 6400 Silver: Cign
Cigna Dental Care DMO Patient Charge Schedules 887394 09/15 CDT 2016 Covered under Procedure Code1 Dental Description and Nomenclature Cigna Dental 01 and 02 PCS Cigna Dental 03 PCS Cigna Dental 04 PCS Cigna Dental 05 PCS Cigna Dental 06 PCS Cigna Dental 07 PCS Cigna Dental 08 PCS Chair Time Per Y/N Minutes Code # (if different) Y/N Code # (if .
rates after bariatric surgery have fallen by 80% in the past decade. Data involving nearly 60,000 bariatric pa-tients from American Society for Metabolic and Bariatric Surgery (ASMBS) Bariatric Centers of Excellence data-base show that the risk of death within the 30 days fol-lowing bariatric surgery av-erages 0.13%, or approxi-
1. Bariatric Clear Liquids: starts the day after surgery. 2. Bariatric Full Liquids: starts the day you go home from the hospital. 3. Bariatric Pureed Food: starts at your 2-week post-op clinic visit. 4. Bariatric Soft Foods: lasts about 2 weeks for Bypass and 4 weeks for the Sleeve. 5. Bariatric Regular diet: Begins at your 2-month post-op .
Post-bariatric surgery health behaviour changes. Post-bariatric surgery diet. Centres that perform bariatric surgery will typically provide pa-tients with a dietary protocol to follow. Initially, over several weeks, patients transition from liquid, to soft and then to a sol-id diet. Over the long term, patients are encouraged to follow
Bariatric Surgery Patient Binder Weight Loss Surgery Bariatric surgery, or weight loss surgery, is a tool to help people lose weight. When accompanied by permanent lifestyle changes, it can help individuals achieve lasting health benefits. Baptist Health Bariatric Center offers the lat-est and safest weight loss surgery options:
Cigna Medicare Supplement Insurance Cigna Health and Life Insurance Company All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. . PO Box 559015, Austin, TX 78755-9015 (866) 459-4272 Application is for: New business .
Before you go, here is a bit of history of 한글 (Hangeul, the Korean alphabet): Korean is the official language of Korea, both North and South. There are around 78 million people who speak Korean around the world. [1] 한글 (the Korean alphabet) was invented by Sejong the Great in the 15th century. Before that time, people
