BARIATRIC SURGERY (REQUIRES PREAUTHORIZATION)

III.212





III.212 BARIATRIC SURGERY (REQUIRES PREAUTHORIZATION)


Policy

INTERQUAL CRITERIA



Dates

  • Original Effective
    01-01-2015
  • Last Review
    05-07-2025
  • Next Review
    05-05-2026

Description

Bariatric surgery is a treatment for morbid obesity in patients who fail to lose weight with conservative measures. There are numerous surgical techniques available. These techniques have heterogeneous mechanisms of action; varying degrees of gastrointestinal restriction that may only serve create a small gastric pouch that leads to restricted eating, or instead lead to malabsorption of nutrients, or finally lead to metabolic changes resulting from gastric and intestinal surgery.

 



Quick Code Search

Use this feature to find out if a procedure and diagnosis code pair will be approved, denied or held for review. Simply put in the procedure code, then the diagnosis code, then click "Add Code Pair". If the codes are listed in this policy, we will help you by showing a dropdown to help you.

Procedure

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Diagnosis

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Codes

      
          Full Description
            Bypass Stomach to Jejunum, Open Approach
      
          Full Description
            Bypass Stomach to Jejunum, Percutaneous Endoscopic Approach
      
          Full Description
            Bypass Stomach to Jejunum, Via Natural or Artificial Opening Endoscopic
      
          Full Description
            Excision of Stomach, Open Approach
      
          Full Description
            Excision of Stomach, Percutaneous Approach
      
          Full Description
            Excision of Stomach, Percutaneous Endoscopic Approach
      
          Full Description
            Excision of Stomach, Via Natural or Artificial Opening
      
          Full Description
            Excision of Stomach, Via Natural or Artificial Opening Endoscopic
      
          Full Description
            Removal of Infusion Device from Stomach, Percutaneous Endoscopic Approach
      
          Full Description
            Removal of Extraluminal Device from Stomach, Percutaneous Endoscopic Approach
      
          Full Description
            Repair Stomach, Percutaneous Endoscopic Approach
      
          Full Description
            Restriction of Stomach with Extraluminal Device, Open Approach
      
          Full Description
            Restriction of Stomach with Intraluminal Device, Open Approach
      
          Full Description
            Restriction of Stomach, Open Approach
      
          Full Description
            Restriction of Stomach with Extraluminal Device, Percutaneous Approach
      
          Full Description
            Restriction of Stomach with Intraluminal Device, Percutaneous Approach
      
          Full Description
            Restriction of Stomach, Percutaneous Approach
      
          Full Description
            Restriction of Stomach with Extraluminal Device, Percutaneous Endoscopic Approach
      
          Full Description
            Restriction of Stomach with Intraluminal Device, Percutaneous Endoscopic Approach
      
          Full Description
            Restriction of Stomach, Percutaneous Endoscopic Approach
      
          Full Description
            Revision of Extraluminal Device in Stomach, Percutaneous Endoscopic Approach
      
          Full Description
            Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon
      
          Full Description
            Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s)
      
          Full Description
            Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
      
          Full Description
            Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption
      
          Full Description
            UNLISTED LAPAROSCOPY PROCEDURE, STOMACH
      
          Full Description
            Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components)
      
          Full Description
            Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only
      
          Full Description
            Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only
      
          Full Description
            Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only
      
          Full Description
            Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components
      
          Full Description
            Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy)
      
          Full Description
            Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty
      
          Full Description
            Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty
      
          Full Description
            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)
      
          Full Description
            Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy
      
          Full Description
            Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption
      
          Full Description
            Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)
      
          Full Description
            REVISION OF GASTRODUODENAL ANASTOMOSIS (GASTRODUODENOSTOMY) WITH RECONSTRUCTION; WITHOUT VAGOTOMY
      
          Full Description
            REVISION OF GASTRODUODENAL ANASTOMOSIS (GASTRODUODENOSTOMY) WITH RECONSTRUCTION; WITH VAGOTOMY
      
          Full Description
            Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy
      
          Full Description
            Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy
      
          Full Description
            Gastric restrictive procedure, open; revision of subcutaneous port component only
      
          Full Description
            Gastric restrictive procedure, open; removal of subcutaneous port component only
      
          Full Description
            Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only
      
          Full Description
            Gastric restrictive procedure, endoscopic sleeve gastroplasty, with esophagogastroduodenoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components
      
          Full Description
            Endoscopic outlet reduction, gastric pouch application, with endoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components




Revisions

05-02-2024

Policy reviewed at Medical Policy Committee meeting on 05/01/2024 – no changes to policy.
06-28-2023

Added new codes for 07/01/2023:  C9784 C9785
12-20-2022

Added new codes effective 01/01/2023  43290 43291
12-09-2020

Added revision codes 43850, 43855, 43860, 43865
10-07-2020

Removed CPT code 43633
09-06-2018

Added CPT 43633