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Date Printed: December 17, 2017: 04:35 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Subject: Bariatric Surgery

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This medical coverage guideline is not an authorization, certification, explanation of benefits, or a guarantee of payment, nor does it substitute for or constitute medical advice. All medical decisions are solely the responsibility of the patient and physician. Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. This medical coverage guideline applies to all lines of business unless otherwise noted in the program exceptions section.

 

DESCRIPTION

Weight loss surgery, also called bariatric surgery, is performed to treat morbid obesity. To be considered a morbidly obese adult, you must have a body mass index or BMI of 40 kg/m2 or greater. If you have a BMI of 35kg/m2 or greater with other related problems, such as diabetes or sleep apnea, you may also be considered morbidly obese.

To be considered morbidly obese if you are under 18 years of age, you must have a BMI of 50 kg/m2 or greater, with at least one less serious related problem. Examples include high blood pressure or an abnormal amount of cholesterol or fat in your blood. If you have a body mass index or BMI of 40 kg/m2 or greater, with at least one serious related problem, such as diabetes or sleep apnea, you may also be considered morbidly obese.

Visit the BMI calculator at WebMD for more information.

Surgery procedures for treating obesity fall into two categories. In the first category, the procedure creates a small stomach pouch. The smaller size reduces the amount of food required to feel full. This decreases the amount of food a person eats. Procedures in the other category change the path of food through the digestive tract. This causes less of the food to be absorbed. In some cases, procedures from both categories are combined.

Visit the Clinical View of this guideline for more information.

Visit WebMD for more information on surgery for clinically severe obesity.

COVERAGE

 

Note: For all medical decisions about this service, Florida Blue uses the Position Statement in the Clinical View of this medical coverage guideline. To make the best decision for your health needs, talk to your doctor. The services covered vary from health plan to health plan. Bariatric surgery may be excluded by contract. Refer to your health plan contract for complete information about your coverage.

 

If your health plan covers surgery for morbid obesity, the following procedures may be covered if certain requirements are met:

• Roux-en-Y Gastric Bypass

• Laparoscopic Adjustable Gastric Banding

• Biliopancreatic Bypass with Duodenal Switch

• Biliopancreatic Bypass (Scopinaro procedure)

• Sleeve gastrectomy

All other procedures are considered experimental or investigational and are not covered. Published clinical evidence does not support using other procedures.

PROGRAM EXCEPTIONS

• Federal Employee Program (FEP): Certain exceptions apply.

• State Account Organization (SAO): Certain exceptions apply.

• Medicare Advantage products: Certain exceptions apply.

Visit the Clinical View of this guideline for more coverage information.

Refer to your health plan contract for complete information about your coverage.

Date Printed: December 17, 2017: 04:35 PM