Obesity is the most frequent form of malnutrition in the developed world and it is increasing. Morbid obesity (i.e., obesity with secondary serious or debilitating progressive disease) is generally associated with a body mass index (BMI) of ≥40 kg/m²  (i.e. weight/height squared). Morbid obesity has a significant impact on cardiac risk factors, incidence of diabetes, obstructive sleep apnea, debilitating arthritis of weight bearing joints, infertility, psychosocial and economic problems and various types of cancers, etc.

The first treatment of morbid obesity is dietary and lifestyle changes. When conservative treatment fails, a few patients may require a surgical approach. The National Institutes for Health defines potential candidates for surgery as those with a BMI of 40 kg/m² or more or a BMI between 35 kg/m² and 39.9 kg/m² and a serious obesity-related health problem such as type 2 diabetes, coronary heart disease, or severe sleep apnea. Additionally, persons should have acceptable operative risks, the ability to participate in treatment and long-term follow-up, and possess an understanding of the surgical procedure and necessary life style changes.

Surgery for morbid obesity, also known as bariatric surgery is based on intestinal malabsorption and gastric reduction. Surgery is considered successful if weight loss is maintained at greater than or equal to 50% of excess body weight for more than 10 years.

Several different gastric reduction and intestinal malabsorption procedures are listed below:

Gastric reduction (gastric restrictive) procedures:

• Vertical-banded gastroplasty
• Adjustable gastric banding
• Gastric bypass (Roux-en-Y gastroenterostomy); this can be done by both open or laparoscopic approach
• Mini-gastric bypass (laparoscopic)
• Sleeve gastrectomy; performed  as a stand-alone procedure or in combination with malabsorptive procedures

Malabsorptive Procedures:

• Biliopancreatic bypass (Scopinaro Procedure)
• Biliopancreatic bypass with duodenal switch

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Policy: 

The following surgical procedures for the treatment of morbid obesity may be considered medically necessary when the criteria listed below are met:

• Vertical-banded gastroplasty
• Gastric bypass (Roux-en-Y gastroenterostomy) with short Roux limb equal to or less than 150 cm; this can be done by either open or laparoscopic approach 
• Adjustable gastric banding (Lap-Band®  procedure)
• Biliopancreatic bypass (i.e., the Scopinaro procedure) with duodenal switch; this can be done by either open or laparoscopic approach

General Criteria for Coverage:

• Patient is at least 18 years old

And

• The patient must have documentation in the medical record of failure to sustain weight loss within the two years preceding surgery and documentation of the health care provider’s monitoring of the patient’s progress toward a goal of weight loss.  

And

• The patient must be a motivated individual with acceptable operative risk and must be evaluated by a licensed mental health provider to determine the patient's willingness to comply with pre and postoperative treatment plans, and a strategy to ensure cooperation with follow-up must be documented.

And, in addition to the general requirements above, the patient must also meet one of the following weight criteria:

• BMI of 40kg/m² for at least 3 years
• BMI of ≥ 50 kg/m² for biliopancreatic bypass (i.e., the Scopinaro procedure) with duodenal switch  

Or

• BMI of greater than 35kg/m² in conjunction with one of the following:
  • Hypertension requiring medication for at least one year
  • Diabetes Mellitus type 2 requiring medication for at least one year
  • Obstructive sleep apnea, confirmed by sleep study, which does not respond to conservative treatment
  • Documented cardiovascular disease
  • Pulmonary hypertension of obesity

Sleeve gastrectomy, as a stand-alone procedure or when combined with a malabsorptive procedure, may be considered medically necessary for patients meeting the above general criteria and one of the following weight criteria:

• BMI ≥ 40 kg/m²  for at least 3 years

Or

• BMI ≥ 35  kg/m²   in conjunction with one of the following:
  • Hypertension requiring medication for at least one year
  • Diabetes mellitus type 2 requiring medication for at least one year
  • Obstructive sleep apnea, confirmed by a sleep study, which does not respond to conservative treatment
  • Documented cardiovascular disease
  • Pulmonary hypertension of obesity

AND one of the following:

• History of transplant, i.e., any solid organ or allogeneic or autologous stem cell
• Chronic corticosteroid use
• Anti-platelet therapy, i.e., aspirin, Plavix® (clopidogrel bisulfate), Ticlid® (ticlopidine hydrochloride), Effient® (prasugrel)
• Inflammatory bowel disease
• History of gastritis or peptic ulcer disease

The following surgical procedures for the treatment of morbid obesity are considered investigational:

• Sleeve gastrectomy in patients other than as described above
• Mini-gastric bypass (laparoscopic)
• Biliopancreatic bypass (Scopinaro Procedure)
• Long-limb ( > 150 cm) gastric bypass

Endoscopic procedures, including but not limited to the StomaphyX^TM device, to treat weight gain after bariatric surgery due to large gastric stoma or large gastric pouches are considered investigational.

Bariatric surgery is considered investigational as a cure for type 2 diabetes mellitus.

Subsequent bariatric procedures, including revisions, in patients *****gain weight due to failure to comply with lifestyle or dietary modifications are considered not medically necessary.