Medical Policy: 02.01.56
Original Effective Date: December 2015
Reviewed: July 2017
Revised: July 2017
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.
Bariatric is an internationally accepted term applied to patients who have a weight that far exceeds recommended guidelines and / or a body size that restricts their mobility, health, or access to available services. Multiple surgical and laparoscopic procedures are available for the treatment of obesity. The following miscellaneous bariatric procedures have been used to treat obesity.
The Intragastric balloon (also known as the silicone intragastric balloon or SIB) has been developed as a temporary aid for obese patients who have had unsatisfactory results in their clinical treatment for obesity. Intragastric balloon is intended to reduce gastric capacity, causing satiety, making it easier for patients to take smaller amounts of food.
Vertical banded gastroplasty (VBG), also known as stomach stapling. In this procedure the upper stomach near the esophagus is stapled vertically to create a small pouch along the inner curve of the stomach. The outlet from the pouch to the rest of the stomach is restricted by a band made of special material. The band delays the emptying of food from the pouch, causing a feeling of fullness. The percentage of reoperations necessary with vertical banded gastroplasty is increased from all other approved procedures. This procedure is no longer the standard of care.
Intestinal Bypass, (e.g., jejunoileal) bypass is created by dividing the small bowel 30 cm distal to the ligament of Treitz. The proximal cut end of the small bowel is anastomosed to the terminal ileum 50 cm proximal to the ileocecal valve. The rest of the small bowel remains a blind loop.
The Mini gastric bypass or Single-Anastomosis Gastric Bypass (similar to the Billroth II operation, can also be called Gastrojejunostomy intestinal anastomosis) mini-gastric bypass is a variation of the gastric bypass. 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.
Long Limb Gastric Bypass The long-limb gastric bypass differs from the conventional gastric bypass only in the length of defunctionalized jejunum. The long-limb gastric bypass was designed to induce greater malabsorption by diverting bile and pancreatic secretions distally in the digestive tract. This was felt to produce a greater malabsorption of fats without the protein malabsorption associated with intestinal bypass.
Gastrointestinal liners including but not limited to the EndoBarrier, an endoscopically delivered duodeno-jejunal bypass liner (DJBL), is a plastic flexible tube that is placed in the duodenal bulb, directly behind the pylorus. It extends from the duodenum to the proximal jejunum.
Transoral gastroplasty (TG) is a minimally invasive, incisionless, reversible weight-loss procedure in which the stomach size is restricted with staples or sutures by using endoscopic surgical tools guided through the mouth and esophagus into the stomach. Two examples of this procedure that are proposed for revisions of standard weight loss surgery are Stomaphyx and the ROSE procedure. This may also be referred to as endoscopic sleeve gastroplasty.
In a traditional gastric bypass procedure, surgeons create a smaller stomach by stapling off a large section. A problem with the traditional procedure is that the staples can break down, causing the stomach to regain its original shape -- and patients to start gaining weight again. Also, the stomach opening that leads into the intestines, which in surgery is made smaller to allow less food to pass through, often stretches as the years go by. With the Fobi pouch, there is no use of staples; rather, the stomach is bisected and hand-sewn to maintain the separation. A synthetic band is placed around the stomach opening to keep it from stretching.
This procedure is intended to provide control of calorie consumption to those with BMI 35-55 kg/m² who have been unsuccessful in weight loss through non-surgical means. To place the device, surgeons insert a tube in the stomach with an endoscope via a small incision in the abdomen. A disk-shaped port valve that lies outside the body, flush against the skin of the abdomen, is connected to the tube and remains in place. Approximately 20 to 30 minutes after meal consumption, the patient attaches the device’s external connector and tubing to the port valve, opens the valve and drains the contents. Once opened, it takes approximately five to 10 minutes to drain food matter through the tube and into the toilet. The device removes approximately 30 percent of the calories consumed. Only 1 randomized control trial has been initiated, with no literature available on the long-term effects of therapy on health outcomes. With no completed randomized control trials the evidence is lacking that proves device use shows an improvement in net health outcomes or that the service is as beneficial as any established alternative service.
Bariatric Arterial Embolization/Gastric Artery Embolization (Nanoblock procedure)
During this procedure a small catheter is passed through the radial artery in the wrist or the femoral artery in the groin and utilize live x-ray imaging to guide the catheter to the artery that supplies blood to the left side of the stomach. Here the physician injects tiny particles that are just large enough to block and kill the cells that make the appetite hormone ghrelin.
Orally administered hydrogel capsules
Hydrogel capsules (i.e Gelesis100) are pills that are designed to treat the physiological symptoms of hunger without surgery, other invasive procedures or systemically absorbed drugs. Twenty minutes before a meal, a patient swallows capsules containing hydrogel particles. Once in the stomach, these particles are released from the capsules and rapidly absorb water, hydrating to approximately one hundred times their dry weight. The particles will pass through the digestive tract and be excreted from the body.
For information pertaining to gastric electrical stimulation, see policy 07.01.62
Bariatric surgical procedures are considered investigational for individuals with a BMI of 30-34.9 kg/m².
Bariatric surgery as a treatment for type-2 diabetes is considered investigational.
Based upon our criteria and assessment of the peer-reviewed literature the following procedures are considered investigational:
To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes and / or diagnosis codes.
Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc. They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.
*CPT® is a registered trademark of the American Medical Association.