THIS IS FOREIGN LANGUAGE TO ME GARY HELP/ ANYBODY
CIGNA HEALTHCARE COVERAGE POSITION Subject Bariatric Surgery Revised Date ............................. 5/15/2008 Original Effective Date ............. 5/15/2004 Next Review Date……………….5/15/2009 Coverage Position Number ............. 0051 Table of Contents Coverage Position............................................... 1 General Background ........................................... 3 Coding/Billing Information ................................. 23 References........................................................ 25 Hyperlink to Related Coverage Positions Abdominoplasty and Panniculectomy Gastric Pacing/Gastric Electrical Stimulation (GES) Nutritional Counseling Obstructive Sleep Apnea Diagnosis and Treatment Services Redundant Skin Surgery INSTRUCTIONS FOR USE Coverage Positions are intended to supplement certain standard CIGNA HealthCare benefit plans. Please note, the terms of a
participant’s particular benefit plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage,
Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which
these Coverage Positions are based. For example, a participant’s benefit plan document may contain a specific exclusion related to
©2008 CIGNA Coverage Position Bariatric surgery is specifically excluded under many CIGNA HealthCare benefit plans and may be governed by state and/or federal mandates. Please refer to the applicable benefit plan document to determine benefit availability and the terms and conditions of coverage. Unless excluded from the benefit plan, this service is covered when the following medical necessity criteria are met. CIGNA HealthCare covers bariatric surgery using a covered procedure outlined below as medically necessary when ALL of the following criteria are met: • The individual is ≥ 18 years of age or has reached full expected skeletal growth AND has evidence of one of the following: �� BMI (Body Mass Index) ≥ 40 for at least the previous 24 months. �� BMI (Body Mass Index) 35–39.9 for at least the previous 24 months with at least one clinically significant comorbidity, including but not limited to, cardiovascular disease, Type 2 diabetes, hypertension, coronary artery disease, or pulmonary hypertension • Active participation within the last two years in one physician-supervised weight-management program for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of ALL of the following components: Page 2 of 34 Coverage Position Number: 0051 �� weight �� current dietary program �� physical activity (e.g., exercise program) Programs such as Weigh****chers®, Jenny Craig® and Optifast® are acceptable alternatives if done in conjunction with physician supervision and detailed documentation of participation is available for review. For individuals with long-standing, morbid obesity, participation in a program within the last five years is sufficient if reasonable attendance in the weight-management program over an extended period of time of at least six months can be demonstrated. However, physiciansupervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement. • Evaluation by a multidisciplinary team within the previous 12 months whi*****ludes the following: �� an evaluation by a surgeon qualified to do bariatric surgery recommending surgical treatment �� a separate medical evaluation recommending bariatric surgery �� clearance for surgery by a mental health provider �� a nutritional evaluation by a physician or registered dietician Bariatric Surgery Procedures: When the specific medical necessity criteria noted above for bariatric surgery have been met, CIGNA HealthCare covers ANY of the following bariatric surgery procedures: • vertical banded gastroplasty • Roux-en-Y gastric bypass • adjustable silicone gastric banding (e.g., LAP-BAND®, REALIZE™ ) • biliopancreatic diversion with duodenal switch (BPD/DS) for individuals with a BMI (Body Mass Index) > 50 CIGNA HealthCare covers adjustment of a silicone gastric banding as medically necessary to control the rate of weight loss and/or treat symptoms secondary to gastric restriction following a medically necessary adjustable silicone gastric banding procedure. CIGNA HealthCare does not cover the following bariatric surgery procedures, because they are considered experimental, investigational or unproven (this list may not be all-inclusive): • Fobi-Pouch (limiting proximal gastric pouch) • intragastric balloon • mini-gastric bypass • sleeve gastrectomy (SG) • Natural Orifice Transluminal Endoscopic Surgery™ (NOTES™) (e.g., StomaphyX™) Reoperation and Repeat Bariatric Surgery: CIGNA HealthCare covers surgical reversal (i.e., takedown) of bariatric surgery as medically necessary when the individual develops complications from the original surgery such as stricture or obstruction. 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: Page 3 of 34 Coverage Position Number: 0051 • 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 for revision or conversion surgery and is not covered by CIGNA HealthCare. Cholecystectomy and Liver Biopsy: CIGNA HealthCare covers cholecystectomy performed at the time of bariatric surgery as medically necessary when the bariatric surgery is determined to be medically necessary and EITHER of the following criteria is met: • Preoperative or intraoperative evidence of gallstones or biliary sludge. • Recent history of cholecystitis. CIGNA HealthCare does not cover either prophylactic cholecystectomy (incidental removal of a nondiseased gallbladder) or routine liver biopsy at the time of bariatric surgery, because each is considered experimental, investigational or unproven. General Background Obesity and overweight are defined clinically using the body mass index (BMI). BMI is an objective measurement and is currently considered the most reproducible measurement of total body fat. The National Heart, Lung and Blood Institute (NHLBI) (1998) defines the following classifications based on BMI. The NHLBI recommends that the BMI should be used to classify overweight and obesity and to estimate relative risk for disease compared to normal weight: Classification BMI Underweight < 18.5 kg/m2 Normal weight 18.5–24.9 kg/m2 Overweight 25–29.9 kg/m2 Obesity (Class 1) 30–34.9 kg/m2 Obesity (Class 2) 35–39.9 kg/m2 Extreme Obesity (Class 3) ≥ 40 kg/m2 BMI is a direct calculation based on height and weight, regardless of gender: BMI = ( ) ( ) height m2 weight kg OR 703 ( ) ( ) 2 x height in weight lb ⎥⎦ ⎤ ⎢⎣ ⎡ Page 4 of 34 Coverage Position Number: 0051 Clinically severe or morbid obesity is defined as a BMI greater than or equal to 40 or a BMI 35–39.9 with comorbid conditions. Comorbidities of morbid obesity that need to be considered include any of the following: • mechanical arthropathy (weight-related degenerative joint disease) • type 2 diabetes • clinically unmanageable hypertension (systolic blood pressure at least 140 mm Hg or diastolic blood pressure 90 mm Hg or greater, or if individual is taking antihypertensive agents) • hyperlipidemia • coronary artery disease • lower extremity lymphatic or venous obstruction • severe obstructive sleep apnea • obesity-related pulmonary hypertension Another group of individuals who have been identified are the super-obese. Super-obesity has recently been defined in the literature as a BMI greater than 50. Treatment of obesity is generally described as a two-part process: 1. assessment, including BMI measurement and risk factor identification; and 2. treatment/management Obesity management includes primary weight loss, prevention of weight regain and the management of associated risk. During the assessment phase, the individual needs to be prepared for the comprehensive nature of the program, including realistic timelines and goals. Goals for Weight Loss According to the NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (1998), the initial goal of weight-loss therapy should be to reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted, if indicated, through additional assessment. The NHLBI guidelines further state that, optimally, dietary therapy should last at least six months. The rationale for this initial goal is that even moderate weight loss (i.e., 10% of initial body weight) can significantly decrease the severity of obesity-associated risk factors. It can also set the stage for further weight loss, if indicated. Other interventions in obesity management include exercise/physical activity, behavior modification/therapy, pharmacotherapy and, in select individuals, bariatric surgery. Strategies for Weight Loss Nonsurgical strategies for achieving weight loss and weight maintenance involve the following components: • dietary therapy • increased physical activity/exercise • combined therapy (diet and physical activity) • behavioral therapy • pharmacotherapy Weight-loss and weight-maintenance management should employ a program of low-calorie diets, increased physical activity and behavior therapy. Pharmacotherapy may be considered as an adjunct to these methods. The NHLBI guidelines (1998) make the following recommendations regarding these methods: • Dietary therapy: �� Low-calorie diets are recommended for weight loss in overweight and obese persons. Reducing fat as part of a low-calorie diet is a practical way to reduce calories. Page 5 of 34 Coverage Position Number: 0051 �� Optimally, dietary therapy should last at least six months, as many studies suggest that the rate of weight loss decreases after about six months. Shorter periods of dietary therapy typically result in lesser weight reductions. �� The literature suggests that weight-loss and weight-maintenance therapies that provide a greater frequency of contacts between the individual and the practitioner and are provided over the long term should be put in place. This can lead to more successful weight loss and weight maintenance. • Physical activity is recommended as part of a comprehensive, weight-loss therapy and weightmaintenance program because it: �� modestly contributes to weight loss in overweight and obese adults �� may decrease abdominal fat �� increases cardiorespiratory fitness �� may help with maintenance of weight loss • The combination of a reduced-calorie diet and increased physical activity is recommended, since it produces weight loss, decreases abdominal fat and increases cardiorespiratory fitness. • Behavior therapy is a useful adjunct when incorporated into treatment for weight loss and weight maintenance. In addition, the NHLBI recommends that weight-loss drugs approved by the U.S. Food and Drug Administration (FDA) only be used as part of a comprehensive weight-loss program, including diet and physical activity for individuals with a BMI greater than or equal to 30 with no concomitant obesity-related risk factors or diseases, or for individuals with a BMI greater than or equal to 27 with concomitant obesityrelated risk factors or diseases. Clinical supervision is an essential component of dietary management. According to the NHLBI, “frequent clinical encounters during the initial six months of weight reduction appear to facilitate reaching the goals of therapy. During the period of active weight loss, regular visits of at least once per month and preferably more often with a health professional for the purposes of reinforcement, encouragement, and monitoring will facilitate weight reduction” (NHLBI, 1998). Physicians can also provide clinical oversight and monitoring of what are often complex comorbid conditions and can select the optimal and most medically appropriate weight management, nutritional and exercise strategies. Some commercially available diet programs do not consistently provide counselors who are trained and certified as registered dieticians or with other equivalent clinical training. However, diet programs/plans, such as Weigh****chers®, Jenny Craig® or similar plans are acceptable methods of dietary management if there is concurrent documentation of at least monthly clinical encounters with a physician. Surgical Intervention The NHLBI recommends weight-loss surgery as an option for carefully-selected adult patients with clinically severe obesity (BMI of 40 or greater; or BMI of 35 or greater with serious comorbid conditions) when less-invasive methods of weight loss have failed and the patient is at high risk for obesityassociated morbidity or mortality. Bariatric surgery in patients under 18 years of age or in those who have not reached full expected skeletal growth has not been well-studied; therefore, its safety and efficacy have not yet been established in this population. Surgical therapy for morbid obesity is not only effective in producing weight loss but is also effective in improving several significant complications of obesity, including diabetes, hypertension, dyslipidemia, and sleep apnea. The degree of benefit and the rates of morbidity and mortality of the various surgical procedures vary according to the procedure (Bouldin, et al., 2006). Bariatric surgery is not considered a first-line treatment. Even the most severely obese individuals (i.e., super-obese with BMI over 50) can be helped by a preoperative weight loss through a program of reduced-calorie diet and exercise therapy. A study by Jamal et al. (2006) compared outcomes of gastric bypass patients undergoing a mandatory 13 weeks of preoperative dietary counseling (PDC) (n=72) to a group of patients without this requirement (n=252). The PDC group had a higher incidence of obstructive sleep apnea compared to the no-PDC group (p< 0.04). The two groups had similar incidences of obesity-related comorbidities. The dropout rate Page 6 of 34 Coverage Position Number: 0051 prior to surgery was reported to be 50% higher in the PDC group than in the no-PDC group (p<0.05). The no-PDC patients had a statistically greater percentage of EWL (p<0.0001), lower BMI (p<0.015), and lower body weight (p<0.01) at one-year follow-up. Resolution of major comorbidities, complication rates, 30-day postoperative mortality, and postoperative compliance with follow-up were similar in the two groups (Jamal, et al., 2006). Limitations to this study include its lack of randomization and the relatively short-term follow-up of one year which may not have been long enough to demonstrate differences in outcomes. Ali et al. (2007) reported on a series of 351 patients who had undergone LRYGB. The investigators hypothesized that weight loss prior to LRYGB is feasible, would not decrease the expected postoperative weight loss, and might enhance overall weight loss and maintenance. Patients were divided into four groups depending on the percentage of body weight loss achieved before surgery: group 1, none or gain; group 2, <5%; group 3, 5-10%; and group 4, >10%. Data were collected regarding the demographics, body mass index (BMI) change, and excess weight loss. The maximum follow-up was 36 months. Of the 351 patients enrolled in the study, follow-up data was available for 302 at six months, 246 at 12 months, 167 at 24 months and 71 at 36 months. Groups 3 and 4 had significantly greater initial excess weight and BMI (p<0.05) but these became similar after the preoperative weight loss. Most patients (74%) were able to lose weight before surgery, with 36% losing >5% body weight. Patients who lost weight preoperatively demonstrated more excess weight loss and BMI change from baseline that reached statistical significance at several points during follow-up (p<0.05). This study is limited by its retrospective design and loss to follow-up. Alami et al. (2007) performed a prospective randomized trial to determine whether preoperative weight loss results in better outcomes after LRYGB. A total of 61 patients undergoing laparoscopic gastric bypass surgery were assigned preoperatively to either a weight loss group (n=26) with a 10% weight loss requirement or a group that had no weight loss requirements (n=35). The two groups were identical in terms of initial weight, BMI, and incidence of comorbidities. Perioperative complications, operative time, postoperative weight loss, and resolution of co-morbidities were analyzed. Of the 61 patients, data was available for 12 at one-year follow-up. Preoperative weight loss before LRYGB bypass was found to be associated with a decrease in the operating room time (p=0.0084) and an improved percentage of excess weight loss in the short term (p=0.0267). Complication rates were similar in both groups. Preoperative weight loss was also not shown to have a statistically significant impact on the resolution of comorbidities. Study limitations include small sample size and loss to follow-up. The role of preoperative weight loss remains controversial. However, some bariatric surgeons and centers have advocated for preoperative weight loss, as it is believed that patients who are able to achieve this weight loss are most likely to have successful outcomes after surgery. The benefits of a preoperative weight-loss program include all of the following: • identification of those individuals who will be committed to and compliant with the short-term, long-term and lifelong medical management follow-up, behavioral changes, lifestyle changes, and diet and physical exercise regimen required to ensure the long-term success of this surgery • reduction of operative morbidity and surgical risk • improvement in surgical access with weight loss • reduction of the severity of obesity-associated risk factors, such as blood pressure, glucose intolerance, cardiorespiratory function and pulmonary function Access to a multidisciplinary team approach, involving a physician with a special interest in obesity; a surgeon with extensive experience in bariatric procedures, a dietitian or nutritionist; and a psychologist, psychiatrist or licensed mental health care provider interested in behavior modification and eating disorders, is optimal. A mental health evaluation should specifically address any mental health or substance abuse diagnoses, the emotional readiness and ability of the patient to make and sustain lifestyle changes, and the adequacy of their support system. Realistic expectations about the degree of weight loss, the compromises required by the patient and the positive effect on associated weight-related comorbidities and quality of life should be discussed and contrasted with the potential morbidity and operative mortality of bariatric surgery.
SweetyPooh
LAP RYN 3/23/2006
Cigna is pretty easy to deal with if you do all the steps!
First call and make sure YOUR policy does not have an exclusion for WLS. If it does not you need the following:
Medical clearance--this is a leter from your family doc
surgical clearance--letter from WLS
nutritional evaluation
psych evaluation
6 month medically supervised diet--this is where they get really picky! my office has had some det denied because they were not 180 days long. You doc has to document your vital signs, weight, diet plan and exercise plan you are on each and every month for a total of 6 months and make sure its 180 days. Also make sure your doc does nto document anything else, onlky diet and exercise notes, not sore throat, etc. Your doc cannot only write a letter on your behalf, you have to show monthly documentation.
Also, you have to show a 2 year history of obesity, you do this by showing something with your weight on it for the past 2 years (medical records)
You will be fine
Bonnie
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