Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 1 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. [MPMPPC120903]

Disclaimer Refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefit on all plans or the plan may have broader or more limited benefits than those listed in this Medical Policy.

Description The goal for surgical treatment of obesity is to reduce the impact of serious illness or comorbidities that are induced or aggravated by obesity. Weight-loss surgery should be used only for those members who have tried and failed other methods of treatment, including a medically supervised weight loss program. Weight loss surgery is an option for carefully selected patients with a BMI of 35 to 39.9 kg/m2 who are at a high risk for increased morbidity. A successful surgical outcome depends upon the member’s motivation, education and psychological state.

Coverage Determination

Bariatric surgery requires Prior Authorization. Logon to Pres Online to submit a request: https://ds.phs.org/preslogin/index.jsp Bariatric surgery procedures performed to treat comorbid conditions associated with morbid obesity are a covered benefit.

I. Bariatric surgery is covered when ALL of the following criteria are met:

A. The patient must be 18 years of age or older. AND

B. Appropriate non-surgical treatment should have been attempted prior to surgical treatment for obesity, as evidenced by documented oversight of a structured diet program (at minimum three counseling) within the past year supervised by a physician and/or appropriately licensed nutrition specialist, such as a registered dietician or a licensed nutritionist. Physician programs which only provide pharmacological management are not sufficient. Documented oversight includes records of weight/BMI, dietary program, exercise regimen, behavioral health interventions and pharmacotherapies, if any. The documented BMI at the starting date of the diet program is the BMI used for bariatric surgery.

AND C. The member will attend a weight loss seminar presented by the

bariatric center where the surgery will be performed; the weight loss seminar explains the various aspects of weight loss surgery, including available surgical options, potential complications and supportive resources.

Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 2 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

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AND D. Behavioral health assessment and clearance by a licensed

psychologist or psychiatrist associated with or recommended by the specific surgical program to which the patient has been referred. Evaluation should address potential difficulties the patient may have in adapting to the physical/psychological and other lifestyle/eating changes that will result from the surgery. Specifically, assessment should address: a) The presence of psychiatric risks or active substance abuse that would affect the ability to follow healthcare instruction, b) eating patterns and eating disorders that may require psychotherapeutic intervention either pre- or post-operatively, and c) the patient’s expectations with respect to outcome and whether those expectations are likely to facilitate or hinder adjustment to the necessary behavioral changes. Psychological testing should include objective/normed instruments for depression, anxiety, or other psychiatric risks.

AND E. Must meet one of the following physiologic parameter:

1. A BMI of 40 kg/m or greater; OR

2. A BMI ≥ 35 kg/m², and one or more serious obesity-related co-morbidities that put the member clearly at risk for decreased life expectancy if weight is not lost. Member must have demonstrated adherence with all prescribed medications and treatment instructions. Appropriate documentation is required. Specific obesity-related comorbidities include, but are not limited to: • Cardiomyopathy. • Congestive heart failure with an ejection fraction of 50% or

less than predicted. • Documentation of previous myocardial infarction requiring

hospitalization. • Documented Type 2 diabetes mellitus • Uncontrolled /massive leg lymphedema. • Obstructive sleep apnea with a baseline AHI or RDI of 15 or

greater, or currently under treatment with a positive pressure device (CPAP, BiPAP, C-Flex, etc.)

• Obesity related osteoarthritis of the lower extremities for which joint replacement surgery of the knee or ankle has been recommended but deferred due to obesity.

• Pickwickian syndrome or cor pulmonale.

Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 3 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

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• Obesity related hypertension that is clinically significant and unresponsive to medical therapy – Systolic BP 140 or greater and/or diastolic BP 90. Documentation must be provided proving that these conditions persist despite optimal medical treatment as prescribed by the practitioner and member adherence to treatment.

• LDL cholesterol that is clinically significant and unresponsive to medical therapy – greater than 150. Documentation must be provided proving that these conditions persist despite optimal medical treatment as prescribed by the practitioner and member adherence to treatment.

II. Bariatric surgery for all covered members must be performed by an accredited facility by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program as a Comprehensive Center.

III. The following bariatric surgery procedures are covered:

• Open and laparoscopic Roux-n-Y gastric bypass(RYGBP) • Laparoscopic adjustable gastric banding (LAGB) • Open and laparoscopic biliopancreatic diversion with duodenal

switch (BPD/DS) • Laparoscopic Sleeve Gastrectomy (Laparoscopic Sleeve Gastrectomy

for a 'stand-alone' procedure (i.e., not as part of staged procedure or part of failed attempt that moves to an open procedure)

• Single Anastomosis Duodenal Switch (under IRB review)

Exclusions The following bariatric surgery procedures are NOT covered: • Intestinal bypass surgery • Gastric balloon for treatment of obesity • Open or laparoscopic vertical banded gastroplasty • Open adjustable gastric banding’ • Open sleeve gastrectomy • Intestinal by pass • Mini-gastric bypass • Silastic ring vertical gastric bypass (Fobi pouch)

Additional exclusions:

• Life-threatening multisystemic organ failure • Uncontrolled or metastatic malignancy or other serious medical

condition where caloric restriction may compromise the member

Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 4 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

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• Severe or unstable psychiatric illness that would prevent adjustment post-surgery

• Untreated endocrine dysfunction • Pregnancy or lactation • Active systemic infection • Uncontrolled HIV infection • History of unresolved noncompliance, either medical or

psychosocial • History of alcohol or substance abuse within the last six months • History of smoking within the last three months • Coverage plans that exclude bariatric surgery as a benefit

Background There are two major types of weight loss surgery. One type diverts food

from the stomach to a lower portion of the digestive tract, creating malabsorption (Malabsorption Procedure). The other type restricts the size of the stomach and decreases intake (Restrictive Procedure). Some weight loss surgeries combine both types of procedures (Combined Malabsorption and Restrictive Procedure). Reduction in the size of the stomach or malabsorption leads to decreased caloric intake, and results in significant weight loss. The surgeon performing the bariatric surgery should be substantially experienced and be working within an integrated program that provides for adequate and appropriate oversight, assessment, and management of these procedures. This multidisciplinary program should include guidance on diet, exercise and psychosocial concerns before and after surgery. Presbyterian Health Plan’s Clinical Guidelines for the treatment of obesity follow the “Practical Guide to the Identification, Evaluation and Treatment of Overweight and Obesity in Adults,” developed cooperatively by the North American Association for the Study of Obesity and the National Heart, Lung and Blood Institute. These guidelines describe how healthcare professionals can provide their patients with the direction and support needed to effectively lose weight. The guidelines provide information on lifestyle changes, and the appropriate use of pharmacotherapy and surgery as treatment options.

Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 5 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

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Coding The coding listed in this Medical Policy is for reference only. Covered and non-covered codes are included in this list.

Reporting of ICD-10 for the following CPT

For the following CPT/HCPCS codes 43644, 43645, 43770, 43775, 43845, 43846, 43847 and 43848. Note: Assign ICD-10 E66.01 (morbid obesity) as primary. Report a secondary diagnosis from Table 1 and a tertiary diagnosis from Table 2.

For the following CPT/HCPCS codes 43659, 43771, 43772, 43773, 43774, 43886, 43887 and 43888. Coverage for replacing a defective device or correcting a complication in a patient who had met medical necessity for the original procedure and has achieved acceptable weight loss requires reporting of one diagnosis. The following list includes only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary. See ICD-10 codes in Table 3 for covered diagnosis.

2018 Current Procedural Terminology (CPT) Codes

CPT Codes Description

43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less).

43645 Laparoscopy with gastric bypass and small intestine reconstruction to limit absorption. (Do not report 43645 in conjunction with 49320, 43847)

43659 Unlisted laparoscopy procedure, stomach. (Use CPT code 43659 when BOTH the gastric band and subcutaneous port components were removed AND replaced.

43770

Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components). *Note: The diagnosis of K21.0 is not covered for CPT code 43770

43771 Revision of adjustable gastric band component only

43772 Removal of adjustable gastric band component only

43773 Removal and replacement of adjustable gastric band component only

43774 Removal of adjustable gastric band and subcutaneous port components

Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 6 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

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CPT Codes Description

43775

Laparoscopy, surgical, gastric restrictive procedure; Longitudinal Gastrectomy (ie sleeve gastrectomy). Laparoscopic Sleeve Gastrectomy for a 'stand-alone' procedure (i.e., not as part of staged procedure or part of failed attempt that moves to an open procedure)

43842 V-Band and gastroplasty (non-covered)

43843 Gastroplasty w/out V-band (non-covered)

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. (For greater than 150 cm, use 43837.) (For laparoscopic procedure, use 43644.)

43847 With small intestine to limit absorption

43848 Revision, open of gastric restrictive procedure for morbid obesity, other than adjustable gastric band (separate procedure)

43886 Gastric restrictive procedure, open; revision of subcutaneous port component only

43887 Gastric restrictive procedure, open; removal of subcutaneous port component only

43888 Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only

43999 Stomach surgery procedure (non-covered)

2018 HCPCS Code

HCPCS© Codes Description

S2083 Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline

2018- Diagnosis

Coverage for selected bariatric surgery procedures (CPT codes: 43644, 43645, 43770, 43775,

Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 7 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

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43845, 43846, 43847 and 43848), requires reporting three appropriate diagnoses. Report the primary diagnosis as E66.01 (morbid obesity). Report a secondary diagnosis from Table 1 and a tertiary diagnosis from Table 2 below. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

ICD-10 Description (Table 1)

A18.84 Tuberculosis of heart

E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)

E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma

E11.21 Type 2 diabetes mellitus with diabetic nephropathy

E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease

E11.29 Type 2 diabetes mellitus with other diabetic kidney complication

E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema

E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema

E11.3211 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye

E11.3212 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye

E11.3213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral

E11.3219 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye

E11.3291 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye

E11.3292 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye

E11.3293 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral

E11.3299 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye

Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 8 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

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ICD-10 Description (Table 1)

E11.3311 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye

E11.3312 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye

E11.3313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral

E11.3319 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye

E11.3391 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye

E11.3392 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye

E11.3393 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral

E11.3399 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye

E11.3411 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye

E11.3412 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye

E11.3413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral

E11.3419 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye

E11.3491 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye

E11.3492 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye

E11.3493 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral

E11.3499 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye

E11.3511 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye

E11.3512 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye

Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 9 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

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ICD-10 Description (Table 1)

E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral

E11.3519 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye

E11.3521 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye

E11.3522 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye

E11.3523 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral

E11.3529 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye

E11.3531 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye

E11.3532 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye

E11.3533 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral

E11.3539 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye

E11.3541 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye

E11.3542 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye

E11.3543 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral

E11.3549 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye

E11.3551 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye

Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 10 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

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ICD-10 Description (Table 1)

E11.3552 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye

E11.3553 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral

E11.3559 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye

E11.3591 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye

E11.3592 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye

E11.3593 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral

E11.3599 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye

E11.36 Type 2 diabetes mellitus with diabetic cataract

E11.37X1 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye

E11.37X2 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye

E11.37X3 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral

E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication

E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified

E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy

E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy

E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy

E11.44 Type 2 diabetes mellitus with diabetic amyotrophy

E11.49 Type 2 diabetes mellitus with other diabetic neurological complication

Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 11 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

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ICD-10 Description (Table 1)

E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene

E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene

E11.59 Type 2 diabetes mellitus with other circulatory complications

E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy

E11.618 Type 2 diabetes mellitus with other diabetic arthropathy

E11.620 Type 2 diabetes mellitus with diabetic dermatitis

E11.621 Type 2 diabetes mellitus with foot ulcer

E11.622 Type 2 diabetes mellitus with other skin ulcer

E11.628 Type 2 diabetes mellitus with other skin complications

E11.630 Type 2 diabetes mellitus with periodontal disease

E11.638 Type 2 diabetes mellitus with other oral complications

E11.641 Type 2 diabetes mellitus with hypoglycemia with coma

E11.649 Type 2 diabetes mellitus with hypoglycemia without coma

E11.65 Type 2 diabetes mellitus with hyperglycemia

E11.69 Type 2 diabetes mellitus with other specified complication

E11.8 Type 2 diabetes mellitus with unspecified complications

E11.9 Type 2 diabetes mellitus without complications

E13.00 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)

Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 12 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

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ICD-10 Description (Table 1)

E13.01 Other specified diabetes mellitus with hyperosmolarity with coma

E13.10 Other specified diabetes mellitus with ketoacidosis without coma

E13.11 Other specified diabetes mellitus with ketoacidosis with coma

E13.21 Other specified diabetes mellitus with diabetic nephropathy

E13.22 Other specified diabetes mellitus with diabetic chronic kidney disease

E13.29 Other specified diabetes mellitus with other diabetic kidney complication

E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema

E13.319 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema

E13.3211 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye

E13.3212 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye

E13.3213 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral

E13.3219 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye

E13.3291 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye

E13.3292 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye

E13.3293 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral

E13.3299 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye

E13.3311 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye

E13.3312 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye

Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 13 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

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ICD-10 Description (Table 1)

E13.3313 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral

E13.3319 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye

E13.3391 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye

E13.3392 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye

E13.3393 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral

E13.3399 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye

E13.3411 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye

E13.3412 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye

E13.3413 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral

E13.3419 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye

E13.3491 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye

E13.3492 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye

E13.3493 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral

E13.3499 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye

E13.3511 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye

E13.3512 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye

E13.3513 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral

E13.3519 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye

Medical Policy Original Effective Date: 06-23-04

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Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

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ICD-10 Description (Table 1)

E13.3521 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye

E13.3522 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye

E13.3523 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral

E13.3529 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye

E13.3531 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye

E13.3532 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye

E13.3533 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral

E13.3539 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye

E13.3541 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye

E13.3542 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye

E13.3543 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral

E13.3549 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye

E13.3551 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye

E13.3552 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye

E13.3553 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral

Medical Policy Original Effective Date: 06-23-04

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Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

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ICD-10 Description (Table 1)

E13.3559 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye

E13.3591 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye

E13.3592 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye

E13.3593 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral

E13.3599 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye

E13.36 Other specified diabetes mellitus with diabetic cataract

E13.37X1 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, right eye

E13.37X2 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, left eye

E13.37X3 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral

E13.37X9 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye

E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication

E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified

E13.41 Other specified diabetes mellitus with diabetic mononeuropathy

E13.42 Other specified diabetes mellitus with diabetic polyneuropathy

E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy

E13.44 Other specified diabetes mellitus with diabetic amyotrophy

E13.49 Other specified diabetes mellitus with other diabetic neurological complication

E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene

Medical Policy Original Effective Date: 06-23-04

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Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. [MPMPPC120903]

ICD-10 Description (Table 1)

E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene

E13.59 Other specified diabetes mellitus with other circulatory complications

E13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathy

E13.618 Other specified diabetes mellitus with other diabetic arthropathy

E13.620 Other specified diabetes mellitus with diabetic dermatitis

E13.621 Other specified diabetes mellitus with foot ulcer

E13.622 Other specified diabetes mellitus with other skin ulcer

E13.628 Other specified diabetes mellitus with other skin complications

E13.630 Other specified diabetes mellitus with periodontal disease

E13.638 Other specified diabetes mellitus with other oral complications

E13.641 Other specified diabetes mellitus with hypoglycemia with coma

E13.649 Other specified diabetes mellitus with hypoglycemia without coma

E13.65 Other specified diabetes mellitus with hyperglycemia

E13.69 Other specified diabetes mellitus with other specified complication

E13.8 Other specified diabetes mellitus with unspecified complications

E13.9 Other specified diabetes mellitus without complications

E66.2 Morbid (severe) obesity with alveolar hypoventilation

E78.00 Pure hypercholesterolemia, unspecified

Medical Policy Original Effective Date: 06-23-04

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Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

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ICD-10 Description (Table 1)

E78.1 Pure hyperglyceridemia

E78.2 Mixed hyperlipidemia

E78.3 Hyperchylomicronemia

E78.4 Other hyperlipidemia, , ICD-10-CM code has been deleted on or after 10/01/2018

E78.49 Other Hyperlipidemia ICD-10-CM code has been added on or after 10/01/2018

E78.5 Hyperlipidemia, unspecified

G47.33 Obstructive sleep apnea (adult) (pediatric)

G47.36 Sleep related hypoventilation in conditions classified elsewhere

G93.2 Benign intracranial hypertension

I10 Essential (primary) hypertension

I27.29 Other secondary pulmonary hypertension

I27.89 Other specified pulmonary heart diseases

I43 Cardiomyopathy in diseases classified elsewhere

K21.0* Gastro-esophageal reflux disease with esophagitis. *Note: The diagnosis of K21.0 is not covered for CPT code 43770

K75.81 Nonalcoholic steatohepatitis (NASH)

K76.0 Fatty (change of) liver, not elsewhere classified

K76.89 Other specified diseases of liver

M15.3 Secondary multiple arthritis

Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 18 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. [MPMPPC120903]

ICD-10 Description (Table 1)

M15.8 Other polyosteoarthritis

M16.0 Bilateral primary osteoarthritis of hip

M16.10 Unilateral primary osteoarthritis, unspecified hip

M16.11 Unilateral primary osteoarthritis, right hip

M16.12 Unilateral primary osteoarthritis, left hip

M16.2 Bilateral osteoarthritis resulting from hip dysplasia

M16.30 Unilateral osteoarthritis resulting from hip dysplasia, unspecified hip

M16.31 Unilateral osteoarthritis resulting from hip dysplasia, right hip

M16.32 Unilateral osteoarthritis resulting from hip dysplasia, left hip

M16.4 Bilateral post-traumatic osteoarthritis of hip

M16.50 Unilateral post-traumatic osteoarthritis, unspecified hip

M16.51 Unilateral post-traumatic osteoarthritis, right hip

M16.52 Unilateral post-traumatic osteoarthritis, left hip

M16.6 Other bilateral secondary osteoarthritis of hip

M16.7 Other unilateral secondary osteoarthritis of hip

M16.9 Osteoarthritis of hip, unspecified

M17.0 Bilateral primary osteoarthritis of knee

M17.10 Unilateral primary osteoarthritis, unspecified knee

Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 19 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. [MPMPPC120903]

ICD-10 Description (Table 1)

M17.11 Unilateral primary osteoarthritis, right knee

M17.12 Unilateral primary osteoarthritis, left knee

M17.2 Bilateral post-traumatic osteoarthritis of knee

M17.30 Unilateral post-traumatic osteoarthritis, unspecified knee

M17.31 Unilateral post-traumatic osteoarthritis, right knee

M17.32 Unilateral post-traumatic osteoarthritis, left knee

M17.4 Other bilateral secondary osteoarthritis of knee

M17.5 Other unilateral secondary osteoarthritis of knee

M17.9 Osteoarthritis of knee, unspecified

M19.071 Primary osteoarthritis, right ankle and foot

M19.072 Primary osteoarthritis, left ankle and foot

M19.079 Primary osteoarthritis, unspecified ankle and foot

M19.171 Post-traumatic osteoarthritis, right ankle and foot

M19.172 Post-traumatic osteoarthritis, left ankle and foot

M19.179 Post-traumatic osteoarthritis, unspecified ankle and foot

M19.271 Secondary osteoarthritis, right ankle and foot

M19.272 Secondary osteoarthritis, left ankle and foot

M19.279 Secondary osteoarthritis, unspecified ankle and foot

Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 20 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. [MPMPPC120903]

ICD-10 Description (Table 1)

M19.90 Unspecified osteoarthritis, unspecified site

M48.062 Spinal stenosis, lumbar region with neurogenic claudication

M48.07 Spinal stenosis, lumbosacral region

M51.06 Intervertebral disc disorders with myelopathy, lumbar region

M51.36 Other intervertebral disc degeneration, lumbar region

M51.37 Other intervertebral disc degeneration, lumbosacral region

M99.23 Subluxation stenosis of neural canal of lumbar region

M99.33 Osseous stenosis of neural canal of lumbar region

M99.43 Connective tissue stenosis of neural canal of lumbar region

M99.53 Intervertebral disc stenosis of neural canal of lumbar region

M99.63 Osseous and subluxation stenosis of intervertebral foramina of lumbar region

M99.73 Connective tissue and disc stenosis of intervertebral foramina of lumbar region

Tertiary Diagnoses

ICD-10 Tertiary Diagnoses (Table 2)

Z68.35 Body mass index (BMI) 35.0-35.9, adult

Z68.36 Body mass index (BMI) 36.0-36.9, adult

Z68.37 Body mass index (BMI) 37.0-37.9, adult

Z68.38 Body mass index (BMI) 38.0-38.9, adult

Z68.39 Body mass index (BMI) 39.0-39.9, adult

Z68.41 Body mass index (BMI) 40.0-44.9, adult

Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 21 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. [MPMPPC120903]

ICD-10 Tertiary Diagnoses (Table 2)

Z68.42 Body mass index (BMI) 45.0-49.9, adult

Z68.43 Body mass index (BMI) 50-59.9 , adult

Z68.44 Body mass index (BMI) 60.0-69.9, adult

Z68.45 Body mass index (BMI) 70 or greater, adult

Coverage for replacing a defective device or correcting a complication in a patient who had met medical necessity for the original procedure and has achieved acceptable weight loss requires reporting of one diagnosis. The following list includes only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

The following are limited coverage for CPT/HCPCS codes 43659, 43771, 43772, 43773, 43774, 43886, 43887 and 43888

Diagnoses coverage for replacing a defective device or correcting complication

ICD-10 Code Description (Table 3) T85.518A Breakdown (mechanical) of other gastrointestinal prosthetic

devices, implants and grafts, initial encounter

T85.528A Displacement of other gastrointestinal prosthetic devices, implants and grafts, initial encounter

T85.598A Other mechanical complication of other gastrointestinal prosthetic devices, implants and grafts, initial encounter

T85.612A Breakdown (mechanical) of permanent sutures, initial encounter T85.622A Displacement of permanent sutures, initial encounter

T85.638A Leakage of other specified internal prosthetic devices, implants and grafts, initial encounter

T85.692A Other mechanical complication of permanent sutures, initial encounter

T85.79XA Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter

T85.9XXA Unspecified complication of internal prosthetic device, implant and graft, initial encounter

Reviewed 1. Brenda L. Wolfe, Ph.D., Clinical Psychologist, Albuquerque, NM, January 2006

2. Michael D. Lara, MD, Rio Grande Surgeons, PA, El Paso, TX. August 2007, August 2008

Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 22 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. [MPMPPC120903]

References 1. Hayes Directory. ©Winifred S. Hayes, Inc., 2007. • Comparative Effectiveness Review of Bariatric Surgeries for

Treatment of Obesity in Adolescents, Publication date May 17, 2018. [cited 03/27/2019]

• Comparative Effectiveness of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy for Treatment of Type II Diabetics. Annual Review May 30, 2018. Accessed 03/27/2019

2. MCG Guidelines®. Inpatient and Surgical Care, 21st Edition. Last Update 2-2-2017. Accessed 07/24/2018

3. Centers for Medicare and Medicaid Services. “Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity” (100.1), Version Number 5. Effective Date: May 2017. Accessed 07/24/2018

4. CMS, National Coverage Determination (NCD) for Intensive Behavioral Therapy for Obesity (210.12), effective date 11/29/2011

5. MCG Guidelines®. Inpatient and Surgical Care, 21st Edition. Last Update 2-2-2017. Accessed 07/24/2018.

• Gastric Restrictive Procedure with Gastric Bypass, ORG: S-512 (ISC)

• Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy, ORG: S-513 (ISC)

• Gastric Restrictive Procedure, Sleeve Gastrectomy, by Laparoscopy, ORG: S-516 (ISC)

• Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy, ORG: S-515 (ISC)

Approval Signatures: Clinical Quality Committee: Norman White MD Medical Director: David Yu MD

Approval Date March 27, 2019 Publishing History: • Original Effective Date: June 23, 2004

• Review Date: Aug 2005, May 2006, July 2007, July/Aug 2007, Aug/Sept 2008

• Revision Date: Oct 2005, May 2006, Jan 2007, Sept 2007, Sept 2008

• Renumbered to ICR 2.8 (previously 8.5): Jan 2007

Medical Policy Original Effective Date: 06-23-04

Revised Date: 03/27/2019 Page 23 of 23

Bariatric Surgery (Weight Loss Surgery) MPM 2.81 (Commercial)

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. [MPMPPC120903]

• 09-24-08: Transitioned to Medical Policy, Annual Review and Revision

• 01-28-09: Revision • 01-27-10: Annual Review and Revision • 02-23-12: Annual Review and Revision • 08-22-12: Update of language re “All PHP members must utilize a

facility approved by CMS.” • 01-29-14: Annual Review and Update • 03-25-15: Annual Review • 05-23-18: Annual Review • 03-27-19: Annual Review, changed Non-Medicare to Commercial

in the title section. ICD-10 code E78.4 has been deleted on or after 10/01/18 and ICD-10 E78.49 has been added on or after 10/01/2018. No change to criteria

This Medical Policy is intended to represent clinical guidelines describing medical appropriateness and is developed to assist Presbyterian Health Plan and Presbyterian Insurance Company, Inc. (Presbyterian) Health Services staff and Presbyterian medical directors in determination of coverage. This Medical Policy is not a treatment guide and should not be used as such.

For those instances where a member does not meet criteria described in these guidelines, additional information supporting medical necessity is welcome and may be used by the medical director in reviewing the case. Please note that all Presbyterian Medical Policies are available on the Internet at: https://www.phs.org/providers/resources/medical-policy-manual/Pages/manual.aspx