New procedure for gastric bypass patients who have not lost all their weight or are regaining
C. Reoperation and Surgical Revision-The following may be considered medically necessary for patients
whose initial surgery met medical necessity criteria: 1. Surgical reversal (i.e., takedown) when the patient develops complications from the original surgery such as stricture (narrowing) or obstruction. 2. The following are examples of conditions and/or diagnoses for which revisions to the primary surgical procedure for morbid obesity may be covered: a. Weight loss of 20% or more below the ideal body weight; b. Esophagitis (e.g., esophageal reflux); c. Hemorrhage or hematoma complicating a procedure; d. Vomiting (bilious) following gastrointestinal surgery; e. Gastrointestinal complications, (i.e., complications of intestinal (internal) anastomosis and
bypass); f. Stomal dilation, documented by endoscopy;
g. Pouch dilation documented by upper gastrointestinal examination or endoscopy, producing weight
gain of 20% or more provided that the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the patient has been compliant with a prescribed nutrition and
exercise program following the procedure (compliance with diet and exercise must be documented via a detailed evaluation by a mental health provider and/or nutritionist); h. Stomal stenosis after vertical banding, documented by endoscopy, producing vomiting or weight loss of 20% or more; i. Other and unspecified post surgical nonabsorption (i.e., hypoglycemia and malnutrition following gastrointestinal surgery); j. Other post-operative functional disorders (i.e., diarrhea following gastrointestinal surgery); k. Severe dumping syndrome; l. Post-gastric surgery syndromes (i.e., post-gastrectomy syndrome, post-vagotomy syndrome);
m. Disruption of operative wound; n. Staple line failure, documented by upper gastrointestinal examination; o. Disrupted staple line provided there has been prior weight loss.
CIGNA
Reoperation and Repeat Bariatric Surgery:
CIGNA HealthCare covers surgical reversal (i.e., takedown) of bariatric surgery as medically necessary when the CIGNA HealthCare covers revision of a previous bariatric surgical procedure or conversion to another medically necessary procedure due to inadequate weight loss as medically necessary when ALL of the following are met:
• Coverage for bariatric surgery is available under the participant's current health benefit plan.
• There is evidence of full compliance with the previously prescribed postoperative dietary and exercise program.
• Due to a technical failure of the original bariatric surgical procedure (e.g., pouch dilatation) documented on either upper gastrointestinal (UGI) series or esophagogastroduodenoscopy (EGD), the patient has failed to achieve adequate weight loss, which is defined as failure to lose at least 50% of excess body weight or failure to achieve body weight to within 30% of ideal body weight at least two years following the original surgery.
• The requested procedure is a regularly covered bariatric surgery (see above for specific procedures).
NOTE: Inadequate weight loss due to individual noncompliance with postoperative
nutrition and exercise recommendations is not a medically necessary indication
AETNA Repeat Bariatric Surgery:
AETNA:Aetna considers medically necessary surgery to correct complications from bariatric surgery, such as obstruction or stricture.
Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet either of the following medical necessity criteria:
- Conversion to a RYGB or BPD/DS may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or
-
Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the procedure.
