Amy K.
Screwing it up
Feb 09, 2008
So I got the insurance on it's way, I had started on my 6-month diet, and I got really depressed and screwed it up... missed my nutritionist appointment and even started considering NOT doing this and going back to good ol phentermine and adding Alli with it. Grr.... what am I thinking and who am I fooling?
My new boyfriend absolutely is terrified I will die from this surgery. I am going to a seminar at a different hospital and will take him with I think. I want him to understand what I am going to be going through and that it will be okay. I love him for caring but I can't be in this body anymore.
My new boyfriend absolutely is terrified I will die from this surgery. I am going to a seminar at a different hospital and will take him with I think. I want him to understand what I am going to be going through and that it will be okay. I love him for caring but I can't be in this body anymore.
Red Tape
Jan 25, 2008
Section: Miscellaneous
Number: G-24
Topic: Obesity
Effective Date: March 5, 2007
Issued Date: October 8, 2007
Date Last Reviewed:
General Policy Guidelines
Indications and Limitations of Coverage
Medical Treatment
Treatment of obesity (278.00) is excluded from medical coverage. However, covered services for the medical treatment for morbid obesity (278.01) are eligible for reimbursement. Coverage for the medical treatment of morbid obesity is determined according to individual or group customer benefits.
NOTE:
For additional information on the screening and prevention of obesity, refer to the Highmark Preventive Schedule.
Surgical Treatment
There are a variety of surgeries intended for the treatment of morbid obesity. All procedures fall into one of these two categories:
Gastric restrictive surgical procedures (e.g., vertical banded gastroplasty, gastric stapling, laparoscopic adjustable gastric banding, mini-gastric bypass, gastric bypass with Roux-en-Y) create a small gastric pouch, resulting in weight loss from early satiety and decreased dietary intake. The decreased capacity of the stomach reduces the volume of food an individual consumes before feeling full.
Malabsorptive surgical procedures (e. g., biliopancreatic diversion, biliopancreatic diversion with duodenal switch, long-limb gastric bypass, intestinal gastric bypass) bypass a section of the small intestines. Weight loss results from intestinal malabsorption without dietary modification.
The following procedures are covered for the surgical treatment of morbid obesity when all of the patient selection criteria are met. (Note: Coverage for the surgical treatment of morbid obesity is determined according to individual or group customer benefits.)
Laparoscopic adjustable gastric banding (43770)
Laparoscopic adjustable gastric banding (e.g., the Lap-Band system) involves creating a gastric pouch by placing a gastric band around the exterior of the stomach. The band is attached to a reservoir that is implanted subcutaneously in the abdominal fascia in the patient’s upper abdomen. Injecting the reservoir with saline will alter the diameter of the gastric band. This limits food consumption and creates an earlier feeling of fullness. Subsequent adjustments can be made either to tighten or loosen the band to meet individual patient needs.
Roux-en-Y gastric bypass (RY-GBP) {open (43846) or laparoscopic (43644)}
The open Roux-en-Y gastric bypass is considered the gold standard for bariatric surgery. A small (30 cc) proximal gastric pouch is constructed which is then divided from the remainder of the stomach just below the cardia with a short (150 cm or less) Roux-en-Y gastrojejunostomy performed between the proximal gastric pouch and a Roux-en-Y jejunal limb.
Vertical banded gastroplasty and gastric stapling (open) (43842, 43843)
Vertical banded gastroplasty is a type of gastric restrictive procedure, which consists of constructing a small pouch with a restricted outlet along the lesser curvature of the stomach. The outlet may be externally reinforced to prevent disruption or dilation.
Gastric stapling is accomplished by stapling the upper stomach to create a small pouch into which food flows after it’s swallowed. The outlet of this pouch is restricted by a band of synthetic mesh, which slows its emptying, so that the person feels full after only a few bites of food.
Patient Selection Criteria
The patient is morbidly obese;
Morbid obesity is defined as a condition of consistent and uncontrollable weight gain that is characterized by a weight which is at least 100 lbs. or 100% over ideal weight or a BMI of at least 40 (V85.4) or a BMI of 35 (V85.35-V85.39) with comorbidities (e.g., hypertension, cardiovascular heart disease, dyslipidemia, diabetes mellitus type II, sleep apnea).
The patient is at least 18 years old; and
The patient has received non-surgical treatment (e.g., dietitian/nutritionist consultation, low calorie diet, exercise program, and behavior modification) and attempts at weight loss have failed.
The patient must participate in and meet the criteria of a structured nutrition and exercise program. This includes dietitian/nutritionist consultation, low calorie diet, increased physical activity, behavioral modification, and/or pharmacologic therapy, documented in the medical record. This structured nutrition and exercise program must meet all of the following criteria:
The nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and
The nutrition and exercise program(s) must be for a cumulative total of 6 months or longer in duration; and
The nutritional and exercise program must occur within two years prior to the surgery; and
The patient's participation in a structured nutrition and exercise program must be documented in the medical record by an attending physician who supervised the patient's progress. A physician's summary letter is not sufficient documentation. Documentation should include medical records of the physician's on-going assessments of the patient's progress throughout the course of the nutrition and exercise program. For patients who participate in a structured nutrition and exercise program, medical records documenting the patient's participation and progress must be available for review.
The patient must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery. The patient's medical record documentation should indicate that all psychosocial issues have been identified and addressed.
Patient selection is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. The member's understanding of the procedure, and ability to participate and comply with life-long follow-up and the life-style changes (e.g., changes in dietary habits, and beginning an exercise program) are necessary to the success of the procedure.
If the patient does not meet all of the patient selection criteria for bariatric surgery, the procedure will be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied services.
Gastric stapling and gastric bypass surgery reported for the treatment of "morbid obesity" should be processed under the appropriate procedure code 43644, 43842, 43843, 43846, or 43848 respectively. Claims for "vertical banded gastroplasty" should be processed under code 43842. (See Highmark Medical Policy Bulletin S-96 for additional information on laparoscopic surgery.)
In addition, itemized charges reported for gastroduodenostomy and/or surgery should be combined with the stapling, vertical banded gastroplasty or bypass surgery. The gastrojejunostomy in conjunction with gastric stapling, vertical banded gastroplasty or gastric bypass claim should be processed under the appropriate code 43644, 43842, 43843, 43846, or 43848.
A liver biopsy (10021, 10022, 47001, 47100, 47120, 47122, and 47379), upper gastrointestinal endoscopy and esophagogastroduodenoscopy (EGD) (43234-43239, 43241, and 43259) are considered an inherent part of all bariatric surgical procedures (43644, 43645, 43770-43774, 43842-43848, 43886-43888, and S2083). These services are not eligible for separate payment when reported on the same day as a bariatric surgical procedure. When a doctor reports a liver biopsy, upper gastrointestinal endoscopy or EGD with a bariatric surgical procedure, the charges should be combined under the appropriate bariatric surgery procedure code. A participating, preferred, or network provider cannot bill the member for the liver biopsy, upper gastrointestinal endoscopy, or EGD.
Repeat or Revised Bariatric Surgical Procedures (43771-43774, 43848, and 43886-43888)
Conversion of a gastric restrictive procedure without gastric bypass (e.g., laparoscopic adjustable gastric banding, or vertical banded gastroplasty) to a gastric restrictive procedure with gastric bypass (e.g., for morbid obesity)
Revision of a failed gastric restrictive procedure (e.g., restapling of dehisced vertical banded gastroplasty staple line, severe adhesions of the gastric pouch, stenosis of stoma, dilation of stoma)
A Roux-en-Y gastric bypass (43644, 43846) may be considered medically necessary for patients who have not had adequate weight loss (defined as loss of more than 50 percent of excess body weight) from the primary bariatric surgery (e.g. laparoscopic adjustable gastric banding (43770), vertical banded gastroplasty (43842). Since, maximal weight loss is not typically achieved until 1 to 2 years of the primary bariatric surgery (e.g., laparoscopic adjustable gastric banding, or vertical banded gastroplasty), a Roux-en-Y gastric bypass is considered not medically necessary and not covered if performed within two years of the primary bariatric surgery. In addition, a Roux-en-Y gastric bypass following laparoscopic adjustable gastric banding or vertical banded gastroplasty is considered not medically necessary and not covered for patients who have been substantially noncompliant with a prescribed nutrition and exercise program following the primary bariatric surgery. More than one laparoscopic adjustable gastric banding, vertical banded gastroplasty or Roux-en-Y gastric bypass procedure is considered not medically necessary.
Reoperation may be required to either “take-down” or revise the original bariatric procedure. Surgical revision or reversal (i.e., take-down) is covered for members who have complications from the primary procedure demonstrated by diagnostic study (e.g., obstruction, stricture, dilation of the gastric pouch). A reoperation or reversal is considered not medically necessary unless the primary bariatric surgery has resulted in complications, and therefore, it is not covered. (See HMPB Z-35 for additional information on repeat surgical procedures.)
Codes 43771-43774, 43886-43888 represent open or laparoscopic revisions, repairs or removal of the components of laparoscopic adjustable gastric banding. These procedures would be indicated if there was a complication (e.g., infection in the area of the subcutaneous port).
The following procedures are considered experimental/investigational, and therefore, they are not covered. A participating, preferred or network provider can bill the member for the denied service.
Biliopancreatic bypass (the Scopinaro procedure) (43847) or laparoscopic (43645)
The biliopancreatic diversion (BPD) was first reported by Scopinaro, et al, in 1976 as a procedure that combined both gastric restriction and malabsorption. The technique includes a partial gastrectomy to create a 200-300 cc pouch followed by division and anastomosis of the terminal ileum to the stomach. The jejunum is totally excluded from digestive continuity with the distal end anastomosed to the terminal ileum, creating a “common channel” of ileum approximately 50 cm from the ileocecal valve. A high incidence and the severity of complications following BPD have led many surgeons to restrict its use as an operation for the treatment of super obese patients.
Date Last Reviewed: 08/2007
Biliopancreatic bypass with duodenal switch (43845)
The biliopancreatic bypass with duodenal switch is a modification of the biliopancreatic bypass. The most significant difference from the biliopancreatic bypass to the duodenal switch procedure is utilization of a sleeve gastrectomy of the greater curvature rather than a distal gastrectomy and anastomosis of the ileum to the duodenum instead of the stomach.
Date Last Reviewed: 08/2007
Long-limb gastric bypass (i.e., > 150cm) (43847) or laparoscopic (43645)
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.
Date Last Reviewed: 06/2007
Mini-gastric bypass
A 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, similar to a Billroth II procedure.
Date Last Reviewed: 06/2007
Sapala-Wood Micropouch Roux-en-Y gastric bypass
In the Sapala-Wood Micropouch® operation the very top of the stomach is completely divided. It is not stapled. This division results in the creation of a small "micropouch" completely separate from the lower part of the stomach. This Sapala-Wood Micropouch® is about the size of a grape (1-2 cc).
The small intestine is divided into two ends. One end travels upward to be connected to the Sapala-Wood Micropouch®. The other end is attached downward to the side of the distal small intestine to complete the circuit. Food travels down the esophagus, through the Sapala-Wood Micropouch®, to the intestine. It bypasses the stomach. The bottom of the stomach no longer receives any food or liquids. However, the stomach will still function because its nerve and blood supply are intact.
Date Last Reviewed: 09/2006
Sleeve Gastrectomy
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.
Date Last Reviewed: 09/2006
Two-Staged Procedure for Morbid Obesity
In the two-staged procedure, the greater curve of the stomach is removed in the initial procedure, and then a Roux-en-Y technique is used to anastomose the small bowel to the stomach remnant. Bariatric procedures are usually completed in one operative procedure. At this time, multi-staged bariatric procedures are considered experimental/investigational.
Date Last Reviewed: 07/2007
There is a lack of peer reviewed medical literature that contains comparative data that demonstrates the above mentioned procedures are equivalent to or offer any advantage over the accepted alternatives, particularly Roux-en-Y gastric bypass.
Intestinal bypass
The intestinal (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.
When intestinal bypass surgery is reported, the claim should be processed in accordance with Medical Policy Bulletin G-21 (procedures of questionable current usefulness).
For information on gastric electrical stimulation/gastric pacing for treatment of obesity, please refer to Medical Policy Bulletin S-155.
Description
Obesity is an increase in body weight beyond the limitation of skeletal and physical requirements, as a result of excessive accumulation of fat in the body. In general, 20% to 30% above "ideal" bodyweight, according to standard life insurance tables, constitutes obesity. Morbid obesity is further defined as a condition of consistent and uncontrollable weight gain that is characterized by a weight which is at least 100 lbs. or 100% over ideal weight or a body mass index (BMI) of at least 40 or a BMI of 35 with comorbidities (e.g., hypertension, cardiovascular heart disease, dyslipidemia, diabetes mellitus type II, sleep apnea).
Body mass index (BMI) is a method used to quantitatively evaluate body fat by reflecting the presence of excess adipose tissue. BMI is calculated by dividing measured bodyweight in kilograms by the patient's height in meters squared. The normal BMI is 20-25 kg/meters squared.
NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Procedure Codes
10021 10022 43234 43235 43236 43237
43238 43239 43241 43259 43644 43645
43842 43843 43845 43846 43847 43848
47001 47100 47120 47122 47379 43770
43771 43772 43773 43774 43886 43887
43888 S2083
Traditional (UCR/Fee Schedule) Guidelines
Refer to General Policy Guidelines
FEP Guidelines
FEP will cover gastric restrictive procedures, gastric malabsorptive procedures, and combination restrictive and malabsorptive procedures to treat morbid obesity. Morbid obesity is described as a condition in which an individual has a Body Mass Index (BMI) of 40 or more, or an individual with a BMI of 35 or more with co-morbidities who has failed conservative treatment. All eligible members must be age 18 years or over.
Benefits are also available for diagnostic studies and a psychological examination performed prior to the procedure to determine if the patient is a candidate for the procedure.
Comprehensive / Wraparound / PPO / Major Medical Guidelines
Comprehensive and Wraparound
Payment should not be made for medical services performed for the evaluation and treatment of obesity alone unless such services are a necessary treatment of a disease or condition aggravated by obesity (e.g., cardiac and respiratory diseases, diabetes, and hypertension).
Also refer to General Policy Guidelines
Number: G-24
Topic: Obesity
Effective Date: March 5, 2007
Issued Date: October 8, 2007
Date Last Reviewed:
General Policy Guidelines
Indications and Limitations of Coverage
Medical Treatment
Treatment of obesity (278.00) is excluded from medical coverage. However, covered services for the medical treatment for morbid obesity (278.01) are eligible for reimbursement. Coverage for the medical treatment of morbid obesity is determined according to individual or group customer benefits.
NOTE:
For additional information on the screening and prevention of obesity, refer to the Highmark Preventive Schedule.
Surgical Treatment
There are a variety of surgeries intended for the treatment of morbid obesity. All procedures fall into one of these two categories:
Gastric restrictive surgical procedures (e.g., vertical banded gastroplasty, gastric stapling, laparoscopic adjustable gastric banding, mini-gastric bypass, gastric bypass with Roux-en-Y) create a small gastric pouch, resulting in weight loss from early satiety and decreased dietary intake. The decreased capacity of the stomach reduces the volume of food an individual consumes before feeling full.
Malabsorptive surgical procedures (e. g., biliopancreatic diversion, biliopancreatic diversion with duodenal switch, long-limb gastric bypass, intestinal gastric bypass) bypass a section of the small intestines. Weight loss results from intestinal malabsorption without dietary modification.
The following procedures are covered for the surgical treatment of morbid obesity when all of the patient selection criteria are met. (Note: Coverage for the surgical treatment of morbid obesity is determined according to individual or group customer benefits.)
Laparoscopic adjustable gastric banding (43770)
Laparoscopic adjustable gastric banding (e.g., the Lap-Band system) involves creating a gastric pouch by placing a gastric band around the exterior of the stomach. The band is attached to a reservoir that is implanted subcutaneously in the abdominal fascia in the patient’s upper abdomen. Injecting the reservoir with saline will alter the diameter of the gastric band. This limits food consumption and creates an earlier feeling of fullness. Subsequent adjustments can be made either to tighten or loosen the band to meet individual patient needs.
Roux-en-Y gastric bypass (RY-GBP) {open (43846) or laparoscopic (43644)}
The open Roux-en-Y gastric bypass is considered the gold standard for bariatric surgery. A small (30 cc) proximal gastric pouch is constructed which is then divided from the remainder of the stomach just below the cardia with a short (150 cm or less) Roux-en-Y gastrojejunostomy performed between the proximal gastric pouch and a Roux-en-Y jejunal limb.
Vertical banded gastroplasty and gastric stapling (open) (43842, 43843)
Vertical banded gastroplasty is a type of gastric restrictive procedure, which consists of constructing a small pouch with a restricted outlet along the lesser curvature of the stomach. The outlet may be externally reinforced to prevent disruption or dilation.
Gastric stapling is accomplished by stapling the upper stomach to create a small pouch into which food flows after it’s swallowed. The outlet of this pouch is restricted by a band of synthetic mesh, which slows its emptying, so that the person feels full after only a few bites of food.
Patient Selection Criteria
The patient is morbidly obese;
Morbid obesity is defined as a condition of consistent and uncontrollable weight gain that is characterized by a weight which is at least 100 lbs. or 100% over ideal weight or a BMI of at least 40 (V85.4) or a BMI of 35 (V85.35-V85.39) with comorbidities (e.g., hypertension, cardiovascular heart disease, dyslipidemia, diabetes mellitus type II, sleep apnea).
The patient is at least 18 years old; and
The patient has received non-surgical treatment (e.g., dietitian/nutritionist consultation, low calorie diet, exercise program, and behavior modification) and attempts at weight loss have failed.
The patient must participate in and meet the criteria of a structured nutrition and exercise program. This includes dietitian/nutritionist consultation, low calorie diet, increased physical activity, behavioral modification, and/or pharmacologic therapy, documented in the medical record. This structured nutrition and exercise program must meet all of the following criteria:
The nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and
The nutrition and exercise program(s) must be for a cumulative total of 6 months or longer in duration; and
The nutritional and exercise program must occur within two years prior to the surgery; and
The patient's participation in a structured nutrition and exercise program must be documented in the medical record by an attending physician who supervised the patient's progress. A physician's summary letter is not sufficient documentation. Documentation should include medical records of the physician's on-going assessments of the patient's progress throughout the course of the nutrition and exercise program. For patients who participate in a structured nutrition and exercise program, medical records documenting the patient's participation and progress must be available for review.
The patient must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery. The patient's medical record documentation should indicate that all psychosocial issues have been identified and addressed.
Patient selection is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. The member's understanding of the procedure, and ability to participate and comply with life-long follow-up and the life-style changes (e.g., changes in dietary habits, and beginning an exercise program) are necessary to the success of the procedure.
If the patient does not meet all of the patient selection criteria for bariatric surgery, the procedure will be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied services.
Gastric stapling and gastric bypass surgery reported for the treatment of "morbid obesity" should be processed under the appropriate procedure code 43644, 43842, 43843, 43846, or 43848 respectively. Claims for "vertical banded gastroplasty" should be processed under code 43842. (See Highmark Medical Policy Bulletin S-96 for additional information on laparoscopic surgery.)
In addition, itemized charges reported for gastroduodenostomy and/or surgery should be combined with the stapling, vertical banded gastroplasty or bypass surgery. The gastrojejunostomy in conjunction with gastric stapling, vertical banded gastroplasty or gastric bypass claim should be processed under the appropriate code 43644, 43842, 43843, 43846, or 43848.
A liver biopsy (10021, 10022, 47001, 47100, 47120, 47122, and 47379), upper gastrointestinal endoscopy and esophagogastroduodenoscopy (EGD) (43234-43239, 43241, and 43259) are considered an inherent part of all bariatric surgical procedures (43644, 43645, 43770-43774, 43842-43848, 43886-43888, and S2083). These services are not eligible for separate payment when reported on the same day as a bariatric surgical procedure. When a doctor reports a liver biopsy, upper gastrointestinal endoscopy or EGD with a bariatric surgical procedure, the charges should be combined under the appropriate bariatric surgery procedure code. A participating, preferred, or network provider cannot bill the member for the liver biopsy, upper gastrointestinal endoscopy, or EGD.
Repeat or Revised Bariatric Surgical Procedures (43771-43774, 43848, and 43886-43888)
Conversion of a gastric restrictive procedure without gastric bypass (e.g., laparoscopic adjustable gastric banding, or vertical banded gastroplasty) to a gastric restrictive procedure with gastric bypass (e.g., for morbid obesity)
Revision of a failed gastric restrictive procedure (e.g., restapling of dehisced vertical banded gastroplasty staple line, severe adhesions of the gastric pouch, stenosis of stoma, dilation of stoma)
A Roux-en-Y gastric bypass (43644, 43846) may be considered medically necessary for patients who have not had adequate weight loss (defined as loss of more than 50 percent of excess body weight) from the primary bariatric surgery (e.g. laparoscopic adjustable gastric banding (43770), vertical banded gastroplasty (43842). Since, maximal weight loss is not typically achieved until 1 to 2 years of the primary bariatric surgery (e.g., laparoscopic adjustable gastric banding, or vertical banded gastroplasty), a Roux-en-Y gastric bypass is considered not medically necessary and not covered if performed within two years of the primary bariatric surgery. In addition, a Roux-en-Y gastric bypass following laparoscopic adjustable gastric banding or vertical banded gastroplasty is considered not medically necessary and not covered for patients who have been substantially noncompliant with a prescribed nutrition and exercise program following the primary bariatric surgery. More than one laparoscopic adjustable gastric banding, vertical banded gastroplasty or Roux-en-Y gastric bypass procedure is considered not medically necessary.
Reoperation may be required to either “take-down” or revise the original bariatric procedure. Surgical revision or reversal (i.e., take-down) is covered for members who have complications from the primary procedure demonstrated by diagnostic study (e.g., obstruction, stricture, dilation of the gastric pouch). A reoperation or reversal is considered not medically necessary unless the primary bariatric surgery has resulted in complications, and therefore, it is not covered. (See HMPB Z-35 for additional information on repeat surgical procedures.)
Codes 43771-43774, 43886-43888 represent open or laparoscopic revisions, repairs or removal of the components of laparoscopic adjustable gastric banding. These procedures would be indicated if there was a complication (e.g., infection in the area of the subcutaneous port).
The following procedures are considered experimental/investigational, and therefore, they are not covered. A participating, preferred or network provider can bill the member for the denied service.
Biliopancreatic bypass (the Scopinaro procedure) (43847) or laparoscopic (43645)
The biliopancreatic diversion (BPD) was first reported by Scopinaro, et al, in 1976 as a procedure that combined both gastric restriction and malabsorption. The technique includes a partial gastrectomy to create a 200-300 cc pouch followed by division and anastomosis of the terminal ileum to the stomach. The jejunum is totally excluded from digestive continuity with the distal end anastomosed to the terminal ileum, creating a “common channel” of ileum approximately 50 cm from the ileocecal valve. A high incidence and the severity of complications following BPD have led many surgeons to restrict its use as an operation for the treatment of super obese patients.
Date Last Reviewed: 08/2007
Biliopancreatic bypass with duodenal switch (43845)
The biliopancreatic bypass with duodenal switch is a modification of the biliopancreatic bypass. The most significant difference from the biliopancreatic bypass to the duodenal switch procedure is utilization of a sleeve gastrectomy of the greater curvature rather than a distal gastrectomy and anastomosis of the ileum to the duodenum instead of the stomach.
Date Last Reviewed: 08/2007
Long-limb gastric bypass (i.e., > 150cm) (43847) or laparoscopic (43645)
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.
Date Last Reviewed: 06/2007
Mini-gastric bypass
A 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, similar to a Billroth II procedure.
Date Last Reviewed: 06/2007
Sapala-Wood Micropouch Roux-en-Y gastric bypass
In the Sapala-Wood Micropouch® operation the very top of the stomach is completely divided. It is not stapled. This division results in the creation of a small "micropouch" completely separate from the lower part of the stomach. This Sapala-Wood Micropouch® is about the size of a grape (1-2 cc).
The small intestine is divided into two ends. One end travels upward to be connected to the Sapala-Wood Micropouch®. The other end is attached downward to the side of the distal small intestine to complete the circuit. Food travels down the esophagus, through the Sapala-Wood Micropouch®, to the intestine. It bypasses the stomach. The bottom of the stomach no longer receives any food or liquids. However, the stomach will still function because its nerve and blood supply are intact.
Date Last Reviewed: 09/2006
Sleeve Gastrectomy
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.
Date Last Reviewed: 09/2006
Two-Staged Procedure for Morbid Obesity
In the two-staged procedure, the greater curve of the stomach is removed in the initial procedure, and then a Roux-en-Y technique is used to anastomose the small bowel to the stomach remnant. Bariatric procedures are usually completed in one operative procedure. At this time, multi-staged bariatric procedures are considered experimental/investigational.
Date Last Reviewed: 07/2007
There is a lack of peer reviewed medical literature that contains comparative data that demonstrates the above mentioned procedures are equivalent to or offer any advantage over the accepted alternatives, particularly Roux-en-Y gastric bypass.
Intestinal bypass
The intestinal (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.
When intestinal bypass surgery is reported, the claim should be processed in accordance with Medical Policy Bulletin G-21 (procedures of questionable current usefulness).
For information on gastric electrical stimulation/gastric pacing for treatment of obesity, please refer to Medical Policy Bulletin S-155.
Description
Obesity is an increase in body weight beyond the limitation of skeletal and physical requirements, as a result of excessive accumulation of fat in the body. In general, 20% to 30% above "ideal" bodyweight, according to standard life insurance tables, constitutes obesity. Morbid obesity is further defined as a condition of consistent and uncontrollable weight gain that is characterized by a weight which is at least 100 lbs. or 100% over ideal weight or a body mass index (BMI) of at least 40 or a BMI of 35 with comorbidities (e.g., hypertension, cardiovascular heart disease, dyslipidemia, diabetes mellitus type II, sleep apnea).
Body mass index (BMI) is a method used to quantitatively evaluate body fat by reflecting the presence of excess adipose tissue. BMI is calculated by dividing measured bodyweight in kilograms by the patient's height in meters squared. The normal BMI is 20-25 kg/meters squared.
NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Procedure Codes
10021 10022 43234 43235 43236 43237
43238 43239 43241 43259 43644 43645
43842 43843 43845 43846 43847 43848
47001 47100 47120 47122 47379 43770
43771 43772 43773 43774 43886 43887
43888 S2083
Traditional (UCR/Fee Schedule) Guidelines
Refer to General Policy Guidelines
FEP Guidelines
FEP will cover gastric restrictive procedures, gastric malabsorptive procedures, and combination restrictive and malabsorptive procedures to treat morbid obesity. Morbid obesity is described as a condition in which an individual has a Body Mass Index (BMI) of 40 or more, or an individual with a BMI of 35 or more with co-morbidities who has failed conservative treatment. All eligible members must be age 18 years or over.
Benefits are also available for diagnostic studies and a psychological examination performed prior to the procedure to determine if the patient is a candidate for the procedure.
Comprehensive / Wraparound / PPO / Major Medical Guidelines
Comprehensive and Wraparound
Payment should not be made for medical services performed for the evaluation and treatment of obesity alone unless such services are a necessary treatment of a disease or condition aggravated by obesity (e.g., cardiac and respiratory diseases, diabetes, and hypertension).
Also refer to General Policy Guidelines
EEEK!
Jan 24, 2008
I talked to someone at BCBS for my new job today and they said that they DO cover WLS! I have to pay a $500 deductible, then they cover 80%. I'd pay 20$ up to 2500, then they pay the rest! Also, I have to do the 6 months of diet and exercise, which I am going to start documenting RELIGIOUSLY in a Excel document or something and get this ball rolling. By this time next year I could be slimmer!!!!!!!!!!!!!!!!! I'm sooooooooooo psyched and excited that my dream is coming true and I could really truly be losing this weight! God has answered my prayers and all of my research and hard work has paid off!
Setback
Jan 01, 2008
I went to the nutritionist who says that nutritionally I'm not ready for WLS. (rolleyes here) I didn't really get along with her very well and wish I could see someone else. Anyway, the Aetna plan that the new job offers wants 6 months of diet and exercise first so I have to suffer through that garbage for the millionth time in my life. It's depressing. To top it off, I've gained 3 pounds. Honestly, I am reconsidering surgery. I want it so bad I can taste it. I do, I do! But these insurance companies just will not budge and until they do, I feel hopeless. :(
In the meantime, I'm trying really hard to eat 3 meals with no snacks, no eating at night, drinking more water, taking a multivitamin and calcium every day, moving more, and beverages with no calories. I'm also going to add Alli over-the-counter and phentermine again soon so I can at least see some movement on the scale. Those are the least I can do in the meantime. I gotta bring my weight down. I'm going to die if I don't. :(
In the meantime, I'm trying really hard to eat 3 meals with no snacks, no eating at night, drinking more water, taking a multivitamin and calcium every day, moving more, and beverages with no calories. I'm also going to add Alli over-the-counter and phentermine again soon so I can at least see some movement on the scale. Those are the least I can do in the meantime. I gotta bring my weight down. I'm going to die if I don't. :(
New job!
Dec 27, 2007
I got a job offer for an at home transcription job through a hospital in Florida with hospital benefits, which, hopefully are enough to cover WLS. I think they only cover 60% but that's okay because I can make payments on the rest if I have to. I'm filling out the paperwork for the job tomorrow and am so excited. I'll be bustin my butt and workin 2 jobs but it's soooo worth it to me.
Also, I may be getting a house! I am going tomorrow to look at house that is rent with option to buy for 1495 a month. Expensive but worth it in my book. I'm excited about the idea that I can get a house too!
To top it off, I have a boyfriend! He is really funny, sweet, sincere. He isn't all gung-ho about the idea of me going through this surgery but I think he'll understand as time goes on. He is just scared right now.
So that's the update. Things are on an upswing. I hope they keep on swingin!
Also, I may be getting a house! I am going tomorrow to look at house that is rent with option to buy for 1495 a month. Expensive but worth it in my book. I'm excited about the idea that I can get a house too!
To top it off, I have a boyfriend! He is really funny, sweet, sincere. He isn't all gung-ho about the idea of me going through this surgery but I think he'll understand as time goes on. He is just scared right now.
So that's the update. Things are on an upswing. I hope they keep on swingin!
Not all is lost...
Dec 13, 2007
I currently have resumes in to two different companies that both have insurance that pays for gastric bypass surgery. I am hoping one of them calls me back. If not, when I go to the nutritionist meeting on 12/31, I am going to tell her about my situation and go on medication and diet instead until I can get insurance to cover it. I also have information from a local eating disorder program that I may look into. It's not a bad thing; in fact, the hospital said that many times they refer people over to the eating disorder program before surgery. It's amazing the paperwork they want you to fill out and go through for the program. They even have pictures of different body types and ask you to circle what you look like now versus what you want to look like. It's horrifying, really.
My 3 1/2-year-old is really intense. I think she has ADHD and is going in on Monday for an evaluation. I just can't take it anymore. I really hope they offer an explanation for me and help. As a single mother, it is so hard to handle on my own. Being obese doesn't help when I'm trying to chase after her.
I posted on a transcriptionist message board to see if anyone knew any 'nationals' that offer insurance that covers GBx. I got completely REAMED for even considering the idea... told how horrific it is, how many complications there are, how much death is likely, etc. It was more annoying than anything because I've already made up my mind. But the fact that people are so closed-minded about something that saves lives really pissed me off. :(
My 3 1/2-year-old is really intense. I think she has ADHD and is going in on Monday for an evaluation. I just can't take it anymore. I really hope they offer an explanation for me and help. As a single mother, it is so hard to handle on my own. Being obese doesn't help when I'm trying to chase after her.
I posted on a transcriptionist message board to see if anyone knew any 'nationals' that offer insurance that covers GBx. I got completely REAMED for even considering the idea... told how horrific it is, how many complications there are, how much death is likely, etc. It was more annoying than anything because I've already made up my mind. But the fact that people are so closed-minded about something that saves lives really pissed me off. :(
The Seminar
Dec 05, 2007
Today I went to the seminar at the hospital about surgery. I was really impressed with the Internal Medicine doctor who came to talk to us about the surgery and obesity in general. He went out of his way to discuss why surgery is the most effective treatment for obesity and why medications and diet/exercise fail people time and again. He also made me feel better when he said that living with obesity is more dangerous than having the surgery. I never realized how true that really is.
A nutritionist came in to discuss for 120 minutes how to eat after surgery, the supplements we will need (chewable multivitamin, chewable calcium citrate, B12) and the importance of hydration. She was really nice and gave us a lot of insight into what insurance requires for preop diet/exercise too.
I talked to a guy I'm dating tonight and he was once 280 and managed to lose it by eating one meal a day and is now at a healthy weight. He is scared for me (although since he is a guy has a hard time telling me that outright) and is concerned about surgery. He wants to go with me the next time I go see the nutritionist or doctor and talk about options. He thinks I can do it with diet/exercise alone. I'm very leery of this particularly after today but am appreciative of his concerns. :)
My next step is to make an appointment with a dietitian at the hospital for individual one-on-one counseling, then a psych eval (which I've already done an MMPI this year so who knows...) and then that's it! I need to try to get on the M.A. issue though because I know MA will pay for it. So that is a huge thing I Need to get on pronto.
So let's hope this is the start of something FABULOUS for me!!!!!
A nutritionist came in to discuss for 120 minutes how to eat after surgery, the supplements we will need (chewable multivitamin, chewable calcium citrate, B12) and the importance of hydration. She was really nice and gave us a lot of insight into what insurance requires for preop diet/exercise too.
I talked to a guy I'm dating tonight and he was once 280 and managed to lose it by eating one meal a day and is now at a healthy weight. He is scared for me (although since he is a guy has a hard time telling me that outright) and is concerned about surgery. He wants to go with me the next time I go see the nutritionist or doctor and talk about options. He thinks I can do it with diet/exercise alone. I'm very leery of this particularly after today but am appreciative of his concerns. :)
My next step is to make an appointment with a dietitian at the hospital for individual one-on-one counseling, then a psych eval (which I've already done an MMPI this year so who knows...) and then that's it! I need to try to get on the M.A. issue though because I know MA will pay for it. So that is a huge thing I Need to get on pronto.
So let's hope this is the start of something FABULOUS for me!!!!!
Started another blog!
Nov 30, 2007
Made the call
Nov 30, 2007
I called the insurance company and today I spoke with a different person, Rose, who seemed not-too-optimistic about UH paying for surgery. She told me it was 'absolutely' excluded and that even with an appeal would not be covered; that I'd have to talk to my employer about getting a rider or something to pay for it. Great. I've talked to them already and they won't budge. So either I get insurance thru the state or not get surgery. I've read the non-ops board just in case... I really need this surgery to save my life and so I can be there for my children. I can't live like this anymore.
I took the garbage out and brought the Christmas tree from the garage today and incited an asthma attack in myself. My heart raced and pounded, my back ached, I dripped with sweat. Two flights of stairs. It's 20 degrees or less outside and yet I sweat. I don't get it.
I've read about a few non-ops having success with a low calorie, low carb diet and may go for it. I know I need to move more too so am going to try to do Walk Away the Pounds or something with my little girls. They'll love to pretend we are going on a walk! :) Maybe one day mommy won't feel so gross and tired so we actually can. :(
I took the garbage out and brought the Christmas tree from the garage today and incited an asthma attack in myself. My heart raced and pounded, my back ached, I dripped with sweat. Two flights of stairs. It's 20 degrees or less outside and yet I sweat. I don't get it.
I've read about a few non-ops having success with a low calorie, low carb diet and may go for it. I know I need to move more too so am going to try to do Walk Away the Pounds or something with my little girls. They'll love to pretend we are going on a walk! :) Maybe one day mommy won't feel so gross and tired so we actually can. :(
