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Surgery for Clinically Clinical Severe or Morbid Obesity

Service Code
43887 (CPT) Gastric restrictive procedure, open; removal of subcutaneous port component only
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
Medicaid Adult (Age 21+)
Diagnosis Group
Physical Health

Surgery for clinically severe or morbid obesity is performed for long-term surgical weight loss management. This may result in improvement of the co-morbidities of obesity. The goal of the surgery is to reduce the morbidity associated with obesity, and to improve metabolic and organ function. Surgery for clinically severe or morbid obesity (referred to as a bariatric surgical procedure for the purpose of this policy) falls into two general categories: a. gastric-restrictive procedures which create a small gastric pouch resulting in weight loss by producing early satiety and thus decreasing dietary intake because the amount of food that can be eaten at one time is greatly reduced; and b. malabsorptive procedures, which produce weight loss due to malabsorption by altering the normal transit of ingested food through the intestinal tract. Following a malabsorption procedure, the number of calories, fats and nutrients that can be absorbed during digestion is reduced. Some bariatric surgical procedures have both a restrictive and a malabsorptive component.

Limits

The beneficiary must have met all bariatric surgery criteria for the past 12 calendar months prior to the request for surgery.

Required dietician or nutritionist comprehensive evaluation must occur within the past six calendar months before the surgery request and must be face-to-face, not in a group setting.

Required psychological evaluation must document the past six calendar months.

Medical treatment for obesity must have been unsuccessful for the past 12 calendar months prior to the request, including at least three calendar months of treatment provided or supervised by a medical provider.

Monthly encounter notes are required during the supervised treatment period.

Exclusions

Medicaid shall not cover the following:

  • 1. Jejunoileal bypass;
  • 2. Biliopancreatic diversion with or without duodenal switch for a

beneficiary with a BMI < 50 kg/m2;

  • 3. Gastric wrapping;
  • 4. Adjustable gastric banding for a beneficiary with a BMI > 50 kg/m2;
  • 5. Jejunocolostomy;
  • 6. Mini-gastric bypass;
  • 7. Open sleeve gastrectomy;
  • 8. Gastric bypass with roux limb greater than 150 cm for a beneficiary with

a BMI less than 55 kg/m2.;

  • 9. Bariatric surgical procedures for a beneficiary with a BMI less than 35

kg/m2;

  • 10. Gastric electrical stimulation;
  • 11. Revision of a primary bariatric surgical procedure when the beneficiary

does not meet the criteria in Subsection 3.2.4;

  • 12. Staged procedures; or
  • 13. Cosmetic surgery: Weight loss following bariatric surgical procedures

can result in skin and fat folds in locations such as the medial upper arms, lower abdominal area, and medial thighs. Surgical removal of this skin and fat for solely cosmetic purposes is not covered.

Medicaid shall not cover a bariatric surgical procedure or a beneficiary who is:

  • 1. a preadolescent child,
  • 2. a pregnant or breast-feeding adult or adolescent
  • 3. planning to become pregnant within two years of surgery; or
  • 4. not demonstrating mastery of the principles of healthy dietary and

activity habits.

The following conditions are contraindications to a bariatric surgical procedure, and approval cannot be granted until there is health record documentation that the conditions are resolved:

  • 1. untreated major depression or psychosis;
  • 2. binge-eating disorders; or
  • 3. current drug and alcohol abuse.

Age Group Details

18 years of age and older; beneficiaries under 18 are considered on a case-by-case basis under EPSDT

Place of Service

Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Centers.

How to Submit

N/A - No authorization is required

Resources

Surgery for Clinically Clinical Severe or Morbid Obesity

Service Code
43888 (CPT) Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
Medicaid Adult (Age 21+)
Diagnosis Group
Physical Health

Surgery for clinically severe or morbid obesity is performed for long-term surgical weight loss management. This may result in improvement of the co-morbidities of obesity. The goal of the surgery is to reduce the morbidity associated with obesity, and to improve metabolic and organ function. Surgery for clinically severe or morbid obesity (referred to as a bariatric surgical procedure for the purpose of this policy) falls into two general categories: a. gastric-restrictive procedures which create a small gastric pouch resulting in weight loss by producing early satiety and thus decreasing dietary intake because the amount of food that can be eaten at one time is greatly reduced; and b. malabsorptive procedures, which produce weight loss due to malabsorption by altering the normal transit of ingested food through the intestinal tract. Following a malabsorption procedure, the number of calories, fats and nutrients that can be absorbed during digestion is reduced. Some bariatric surgical procedures have both a restrictive and a malabsorptive component.

Limits

The beneficiary must have met all bariatric surgery criteria for the past 12 calendar months prior to the request for surgery.

Required dietician or nutritionist comprehensive evaluation must occur within the past six calendar months before the surgery request and must be face-to-face, not in a group setting.

Required psychological evaluation must document the past six calendar months.

Medical treatment for obesity must have been unsuccessful for the past 12 calendar months prior to the request, including at least three calendar months of treatment provided or supervised by a medical provider.

Monthly encounter notes are required during the supervised treatment period.

Exclusions

Medicaid shall not cover the following:

  • 1. Jejunoileal bypass;
  • 2. Biliopancreatic diversion with or without duodenal switch for a

beneficiary with a BMI < 50 kg/m2;

  • 3. Gastric wrapping;
  • 4. Adjustable gastric banding for a beneficiary with a BMI > 50 kg/m2;
  • 5. Jejunocolostomy;
  • 6. Mini-gastric bypass;
  • 7. Open sleeve gastrectomy;
  • 8. Gastric bypass with roux limb greater than 150 cm for a beneficiary with

a BMI less than 55 kg/m2.;

  • 9. Bariatric surgical procedures for a beneficiary with a BMI less than 35

kg/m2;

  • 10. Gastric electrical stimulation;
  • 11. Revision of a primary bariatric surgical procedure when the beneficiary

does not meet the criteria in Subsection 3.2.4;

  • 12. Staged procedures; or
  • 13. Cosmetic surgery: Weight loss following bariatric surgical procedures

can result in skin and fat folds in locations such as the medial upper arms, lower abdominal area, and medial thighs. Surgical removal of this skin and fat for solely cosmetic purposes is not covered.

Medicaid shall not cover a bariatric surgical procedure or a beneficiary who is:

  • 1. a preadolescent child,
  • 2. a pregnant or breast-feeding adult or adolescent
  • 3. planning to become pregnant within two years of surgery; or
  • 4. not demonstrating mastery of the principles of healthy dietary and

activity habits.

The following conditions are contraindications to a bariatric surgical procedure, and approval cannot be granted until there is health record documentation that the conditions are resolved:

  • 1. untreated major depression or psychosis;
  • 2. binge-eating disorders; or
  • 3. current drug and alcohol abuse.

Age Group Details

18 years of age and older; beneficiaries under 18 are considered on a case-by-case basis under EPSDT

Place of Service

Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Centers.

How to Submit

N/A - No authorization is required

Resources

Gastric restrictive procedure, transoral, endoscopic sleeve gastroplasty (ESG), including argon plasma coagulation, when performed

Service Code
43889 (CPT) Gastric restrictive procedure, transoral, endoscopic sleeve gastroplasty (ESG), including argon plasma coagulation, when performed
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Unlisted procedure, stomach

Service Code
43999 (CPT) Unlisted procedure, stomach
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Enterolysis (freeing of intestinal adhesion) (separate procedure)

Service Code
44005 (CPT) Enterolysis (freeing of intestinal adhesion) (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Duodenotomy, for exploration, biopsy(s), or foreign body removal

Service Code
44010 (CPT) Duodenotomy, for exploration, biopsy(s), or foreign body removal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method (List separately in addition to primary procedure)

Service Code
44015 (CPT) Tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method (List separately in addition to primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Enterotomy, small intestine, other than duodenum; for exploration, biopsy(s), or foreign body removal

Service Code
44020 (CPT) Enterotomy, small intestine, other than duodenum; for exploration, biopsy(s), or foreign body removal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Enterotomy, small intestine, other than duodenum; for decompression (eg, Baker tube)

Service Code
44021 (CPT) Enterotomy, small intestine, other than duodenum; for decompression (eg, Baker tube)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Colotomy, for exploration, biopsy(s), or foreign body removal

Service Code
44025 (CPT) Colotomy, for exploration, biopsy(s), or foreign body removal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Reduction of volvulus, intussusception, internal hernia, by laparotomy

Service Code
44050 (CPT) Reduction of volvulus, intussusception, internal hernia, by laparotomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Correction of malrotation by lysis of duodenal bands and/or reduction of midgut volvulus (eg, Ladd procedure)

Service Code
44055 (CPT) Correction of malrotation by lysis of duodenal bands and/or reduction of midgut volvulus (eg, Ladd procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Biopsy of intestine by capsule, tube, peroral (1 or more specimens)

Service Code
44100 (CPT) Biopsy of intestine by capsule, tube, peroral (1 or more specimens)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of 1 or more lesions of small or large intestine not requiring anastomosis, exteriorization, or fistulization; single enterotomy

Service Code
44110 (CPT) Excision of 1 or more lesions of small or large intestine not requiring anastomosis, exteriorization, or fistulization; single enterotomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision of 1 or more lesions of small or large intestine not requiring anastomosis, exteriorization, or fistulization; multiple enterotomies

Service Code
44111 (CPT) Excision of 1 or more lesions of small or large intestine not requiring anastomosis, exteriorization, or fistulization; multiple enterotomies
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Enterectomy, resection of small intestine; single resection and anastomosis

Service Code
44120 (CPT) Enterectomy, resection of small intestine; single resection and anastomosis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Enterectomy, resection of small intestine; each additional resection and anastomosis (List separately in addition to code for primary procedure)

Service Code
44121 (CPT) Enterectomy, resection of small intestine; each additional resection and anastomosis (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Enterectomy, resection of small intestine; with enterostomy

Service Code
44125 (CPT) Enterectomy, resection of small intestine; with enterostomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Enterectomy, resection of small intestine for congenital atresia, single resection and anastomosis of proximal segment of intestine; without tapering

Service Code
44126 (CPT) Enterectomy, resection of small intestine for congenital atresia, single resection and anastomosis of proximal segment of intestine; without tapering
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Enterectomy, resection of small intestine for congenital atresia, single resection and anastomosis of proximal segment of intestine; with tapering

Service Code
44127 (CPT) Enterectomy, resection of small intestine for congenital atresia, single resection and anastomosis of proximal segment of intestine; with tapering
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required