FL Insurance
Here is BCBSFL's position statement directly from their web site. Note that they say that WLS is not covered under most cases but will be reviewed on an individual basis if an attending doctor writes that it is "medically necessary." Start working with a good group of Doctor's and if it is truly needed, it will probably get approved. Good luck
Date Printed: August 20, 2008: 09:28 PM
Subject: Surgery for Clinically Severe Obesity (Bariatric Surgery; Gastric Bypass Surgery)
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:
Clinically severe obesity is a result of persistent and uncontrollable weight gain that constitutes a present or potential threat to life. For purposes of this medical coverage guideline, clinically severe obesity is defined as a body mass index (BMI) of 35 kg/m2 or greater. See the height and weight tables for Men and Woman, BMI tables (100-195, 200-295, 300-400, and formula for calculating a BMI.
Several surgical (bariatric) procedures are used for the treatment of clinically severe obesity. These procedures can be categorized as follows:
- Malabsorptive procedures - alteration of the intestinal absorption limiting nutrients available to the body OR
- Gastric restrictive procedures - reduction in the capacity of the stomach thereby limiting the amount of food ingested.
Gastric surgical procedures for the treatment of clinically severe obesity include:
- gastric bypass where approximately 90% of the stomach is bypassed and reattached to the proximal jejunum OR
- gastric stapling, vertically banded gastric partition, or vertically banded gastroplasty where a proximal pouch of 30-60 ml and a one centimeter outlet are created by a row of vertical staples and a horizontally placed reinforcing band.
POSITION STATEMENT:
Effective January 1 2005, weight loss surgery is not covered for most contracts. Please refer to the individual member’s contract benefit language.
NOTE: The treating physician must provide a letter with facts supporting medical necessity, for review by the Medical Director.
Certain surgical procedures performed for the treatment of clinically severe obesity meet the definition of medical necessity when ALL of the following conditions are met:
The member:
- meets the above definition of clinically severe obesity,
- has been severely obese for at least five (5) years,
- has attempted a non-surgical management weight loss program (e.g., diet, exercise, drugs) for six (6) consecutive months
- has received psychological or psychiatric evaluation with counseling as needed, prior to surgical intervention;
- does not have a medically treatable cause for the obesity, (e.g., thyroid or other endocrine disorder).
The following procedures meet the definition of medical necessity when the above criteria has been met:
Vertical-Banded Gastroplasty (CPT code 43842)
Vertical-banded gastroplasty was formerly one of the most common gastric restrictive procedures performed in this country but has more recently declined in popularity. In this procedure, the stomach is segmented along its vertical axis. To create a durable reinforced and rate-limiting stoma at the distal end of the pouch, a plug of stomach is removed, and a propylene collar is placed through this hole and then stapled to itself. Because the normal flow of food is preserved, metabolic complications are uncommon. Complications include esophageal reflux, dilation, or obstruction of the stoma, with the latter 2 requiring reoperation. Dilation of the stoma is a common reason for weight regain. Vertical-banded gastroplasty may be performed using an open or laparoscopic approach.
Roux-en-Y Gastric Bypass (CPT code 43644, 43846)
Gastric bypass may be performed with either an open or laparoscopic technique. The original gastric bypass surgeries were based on the observation that post-gastrectomy patients tended to lose weight. The current procedure involves a horizontal or vertical partition of the stomach in association with a Roux-en-Y procedure (i.e., a gastrojejunal anastomosis). Thus, the flow of food bypasses the duodenum and proximal small bowel. The procedure may also be associated with an unpleasant “dumping syndrome,” in which a large osmotic load delivered directly to the jejunum from the stomach produces abdominal pain OR vomiting. The dumping syndrome may further reduce intake, particularly in “sweets eaters”. Operative complications include leakage and marginal ulceration at the anastomotic site. Because the normal flow of food is disrupted, there are more metabolic complications compared to other gastric restrictive procedures. These complications may include iron deficiency anemia, vitamin B-12 deficiency, and hypocalcemia, all of which can be corrected by oral supplementation. Another concern is the ability to evaluate the “blind” bypassed portion of the stomach.
Long Limb Gastric Bypass (i.e., more than 100 cm) (CPT code 43847)
Recently, variations of gastric bypass procedures have been described, consisting primarily of long limb Roux-en-Y procedures, which vary in the length of the alimentary and common limbs. For example, the stomach may be divided with a long segment of the jejunum (instead of ileum) anastomosed to the proximal gastric stump, creating the alimentary limb. The remaining pancreaticobiliary limb, consisting of stomach remnant, duodenum, and length of proximal jejunum is then anastomosed to the ileum, creating a common limb of variable length in which the ingested food mixes with the pancreaticobiliary juices. While the long alimentary limb permits absorption of most nutrients, the short common limb primarily limits absorption of fats. The stomach may be bypassed in a variety of ways (i.e., either by resection or stapling along the horizontal or vertical axis). Unlike the traditional gastric bypass, which is essentially a gastric restrictive procedure, these very long limb Roux-en-Y gastric bypasses combine gastric restriction with some element of malabsorptive procedure, depending on the location of the anastomoses.
NOTE: Coverage of long limb Roux-en-Y procedures is limited to 150 cm.
Laparoscopic Adjustable Gastric Restrictive Devices (CPT code 43770, 43771, 43772, 43773, 43774)
Laparoscopic placement of an adjustable restrictive device involves placing a gastric band around the exterior of the stomach. The band is attached to a reservoir that is implanted subcutaneously in the rectus sheath. Injecting the reservoir with saline will alter the diameter of the gastric band; therefore, the rate - limiting stoma in the stomach can be progressively narrowed to induce greater weight loss, or expanded if complications develop. Because the stomach is not entered, the surgery and any revisions, if necessary, are relatively simple. Complications include slippage of the external band or band erosion through the gastric wall. Adjustable gastric banding has been widely used in Europe. Only FDA-approved adjustable gastric restrictive devices are eligible for coverage.
Biliopancreatic Bypass with Duodenal Switch (43845)
The duodenal switch procedure is essentially a variant of the biliopancreatic bypass. However, instead of performing a distal gastrectomy, a “sleeve” gastrectomy is performed along the vertical axis of the stomach, preserving the pylorus and initial segment of the duodenum, which is then anastomosed to a segment of the ileum, similar to the above procedure, to create the alimentary limb. Preservation of the pyloric sphincter is designed to be more physiologic. The sleeve gastrectomy decreases the volume of the stomach and also decreases the parietal cell mass, with the intent of decreasing the incidence of ulcers at the duodenoileal anastomosis. However, the basic principle of the procedure is similar to that of the biliopancreatic bypass (i.e., producing selective malabsorption by limiting the food digestion and absorption to a short common ileal segment).
Studies are needed to determine the long-term health outcomes of the following procedures, therefore the procedures listed below are considered experimental or investigational when performed for the treatment of clinically severe obesity:
Biliopancreatic Bypass Procedure (i.e., the Scopinaro procedure) (CPT code 43847)
Biliopancreatic bypass (BPB) procedure, developed and used extensively in Italy, was designed to address some of the drawbacks of the original intestinal bypass procedures that have been abandoned due to unacceptable metabolic complications. Many of the complications were thought to be related to bacterial overgrowth and toxin production in the blind, bypassed segment. In contrast, BPB consists of a subtotal gastrectomy and diversion of the biliopancreatic juices into the distal ileum by a long Roux-en-Y procedure.
This procedure consists of the following components:
- A distal gastrectomy functions to induce a temporary early satiety OR the dumping syndrome in the early postoperative period, both of which limit food intake
- A 200-cm long “alimentary tract” consists of 200 cm of ileum connecting the stomach to a common distal segment
- A 300- to 400-cm “biliary tract,” which connects the duodenum, jejunum, and remaining ileum to the common distal segment
- A 50- to 100-cm “common tract,” where food from the alimentary tract mixes with biliopancreatic juices from the biliary tract. Food digestion and absorption, particularly of fats and starches, are therefore limited to this small segment of bowel (i.e., creating a selective malabsorption). The length of the common segment will influence the degree of malabsorption
- Because of the high incidence of cholelithiasis associated with the procedure, patients typically undergo an associated cholecystectomy. Many potential metabolic complications are related to biliopancreatic bypass, including most prominently iron deficiency anemia, protein malnutrition, hypocalcemia, and bone demineralization. Protein malnutrition may require treatment with total parenteral nutrition (TPN). In addition, there have been several case reports of liver failure resulting in death or liver transplant.
Mini-Gastric Bypass (no specific CPT code)
Recently, a variant of the gastric bypass, called the “mini-gastric bypass” has been popularized. Using a laparoscopic approach, the stomach is segmented, similar to a traditional gastric bypass, but instead of creating a Roux-en-Y anastomosis, the jejunum is anastomosed directly to the stomach, similar to a Billroth II procedure. This unique aspect of this procedure is not based on its laparoscopic approach, but rather the type of anastomosis used.
NOTE: CPT code 43846 does not accurately describe the mini-gastric bypass, since this CPT code explicitly describes a Roux-en-Y gastroenterostomy, which is not used in the mini-gastric bypass.
Sleeve gastrectomy (no specific CPT code)
A sleeve gastrectomy is an alternative approach to gastrectomy that can be performed on its own, or in combination with malabsorptive procedures (most commonly biliopancreatic diversion with duodenal switch). In this procedure, the greater curvature of the stomach is resected from the angle of His to the distal antrum, resulting in a stomach remnant shaped like a tube or sleeve. The pyloric sphincter is preserved, resulting in a more physiologic transit of food from the stomach to the duodenum, and avoiding the dumping syndrome (overly rapid transport of food through stomach into intestines) that is seen with distal gastrectomy. This procedure is relatively simple to perform, and can be done by the open or laparoscopic technique. Some surgeons have proposed this as the first in a 2-stage procedure for very high-risk patients. Weight loss following sleeve gastrectomy may improve a patient’s overall medical status, and thus reduce the risk of a subsequent more extensive malabsorptive procedure, such as biliopancreatic diversion.
Endoscopic Procedures for Weight Gain after Bariatric Surgery (no specific CPT Code)
Endoscopic procedures (e.g., insertion of the StomaphyX™ device) to treat weight gain after bariatric surgery to remedy large gastric stoma or large gastric pouches are considered experimental or investigational, as there are insufficient clinical studies to demonstrate the safety and efficacy of endoscopic procedures in the treatment of weight gain after bariatric surgery.
The following procedures reported as gastric bypass or gastroplasty are also considered experimental or investigational as there is insufficient clinical evidence to support effects on health outcomes:
BILLING/CODING INFORMATION:
CPT Coding:
|
43644 |
Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (Roux limb 150 cm or less) |
|
43645 |
Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption (investigational) |
|
43770 |
Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g. gastric band and subcutaneous port components) |
|
43771 |
Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only |
|
43772 |
Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only |
|
43773 |
Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only |
|
43774 |
Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components |
|
43842 |
Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty |
|
43843 |
Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty (investigational) |
|
43845 |
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) |
|
43846 |
Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy (may be done laparoscopically) |
|
43847 |
Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption (may be done laparoscopically) |
There is no specific CPT or HCPCS code to report mini gastric bypass. A laparoscopic approach is used with the mini-gastric bypass. The stomach is segmented similar to a traditional gastric bypass; the jejunum is anastomosed directly to the stomach, similar to a Billroth II procedure. The mini gastric bypass is not based on its laparoscopic approach, but rather the type of anastomosis used.
HCPCS Coding
|
S2083 |
Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline |
ICD-9 Diagnoses Codes That Support Medical Necessity:
|
278.01 |
Morbid obesity |
REIMBURSEMENT INFORMATION:
Bariatric surgical procedures are limited to individuals 18 years and older and are reimbursed based on the procedure performed and not the surgical technique used (e.g., microsurgical, laser, laparoscopic).
PROGRAM EXCEPTIONS:
Federal Employee Program (FEP): Follow FEP guidelines.
State Account Organization (SAO): Follow SAO guidelines.
DEFINITIONS:
Biliopancreatic bypass: gastric restriction rerouting bile and pancreatic juice to the distal ileum.
Garren-Edwards gastric bubble: a free-floating intragastric device made of elastomeric plastic is placed in the stomach via a gastroscope, used for reducing stomach capacity.
Gastric wrapping: the stomach is folded over on itself and a full stomach wrap, i.e. polypropylene mesh, is applied to limit gastric volume.
Gastric banding: a synthetic band rather than staples is used to divide the stomach into a small upper pouch and a lower portion).
Gastric bubble: see definition of Garren-Edwards gastric bubble.
Jejunoileal bypass: shunts food from the jejunum into the ileum, bypassing the small intestine.
Morbid obesity: defined as a body mass index (BMI) of 40 kg/m2 or greater.
Satiety: the quality or state of being fed or gratified to or beyond capacity.
OTHER:
Other index terms for gastric surgery:
Adjustable gastric banding
Bariatric surgery
Billroth II
Gastric bypass surgery
Lap-Band® System (Allergan)
Mini gastric bypass
Long limb gastric bypass
REALIZE™ Adjustable Gastric Band (Ethicon Endo-Surgery)
Roux-en-Y
Scopinaro
Sleeve gastrectomy
Vertical banding
I am also trying to get bcbs fl to pay for lapband surgery. They told me that bcbs state employees (which I am) does not have coverage, bcbs federal employees do. My pcp sent a letter to them and I have called several times to get the status of that letter. They won't even give me a reply to the letter, because they say it is excluded even though it is considered medically necessary. They gave me a phone number that my dr. would have to call. It is a medical review line for dr. only. It is 1-800-727-2227. I have an appt. next week with my dr. She is working with me and I'm sure she will call to see what is going on. If this doesn't work for me I am going to check with vocational rehabilitation of fl. I read on one forum that someone used that with their pcp's letter of recommendation. I am doing everything I can to research all possible avenues. I can't afford to get a loan, so I am praying that either the dr. can do something or voc. rehab will. Good luck and hope one of these alternatives helps someone.
Toni C.
