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Gastrointestinal surgery for obesity, also called bariatric surgery, promotes weight loss by closing off parts of the stomach to make it smaller. Program payment may not be made for treatment of obesity alone since this treatment cannot be considered reasonable and necessary for the diagnosis or treatment of an illness or injury.

Indications and Limitations of Coverage and/or Medical Necessity

CMS National Coverage Policy

Surgical treatment for primary obesity will be covered by Medicare unless the recipient meets all of the following criteria

· A Body Mass Index (BMI) ≥35

· At least one comorbidity related to obesity

· Have been previously unsuccessful with medical treatment for obesity

Bariatric surgical procedures are covered only when performed at facilities that are:

(1) Certified by the American College of Surgeons (ACS) as a Level 1 Bariatric Surgery Center (program standards and requirements in effect February 15, 2006); or

(2) Certified by the American Society for Bariatric Surgery (ASBS) as a Bariatric Surgery Center of Excellence (program standards and requirements in effect February 15, 2006).

Please refer
http://www.cms.gov/MedicareApprovedFacilitie/BSF/list.asp#TopOfPage for Medicare approved facilities.

Surgical procedures for morbid obesity that are covered under national policy for qualifying Medicare beneficiaries include:

· Open and laparoscopic Roux-En-Y Gastric Bypass (RYGBP).

· Open and laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS).

· Laparoscopic Adjustable Gastric Banding (LAGB).

Surgical procedures for morbid obesity that may not covered under national policy for all Medicare beneficiaries include:

· Open adjustable gastric banding

· Open and laparoscopic-sleeve gastrectomy

· Open and laparoscopic vertical-banded gastroplasty

· Gastric balloon

CPT Codes

43644 Lap gastric bypass/roux-en-y

43645 Lap gastr bypass incl smll intestine

43659 Laparoscope proc, stom

Please note: Report CPT Code 43659 when both the gastric band and subcutaneous port components were removed and replaced and this procedure may be covered when reporting one of the following diagnoses:

996.59 Mechanical complication due to other implant and internal device, not elsewhere classified

996.60 Infection and inflammatory reaction due to unspecified device, implant, and graft

996.70 Other complications due to unspecified device, implant, and graft

43770 Lap place gastr adj device

43771 Lap revise gastr adj device

43772 Lap rmvl gastr adj device

43773 Lap replace gastr adj device

43774 Lap rmvl gastr adj all parts

43842 V-band gastroplasty

43843 Gastroplasty w/o v-band

43845 Gastroplasty duodenal switch

43846 Gastric bypass for obesity

43847 Gastric bypass incl small intestine

43848 Revision gastroplasty

43886 Revise gastric port, open

43887 Remove gastric port, open

43888 Change gastric port, open

43999 Stomach surgery procedure

Please note: CPT code 43999 identifies any of the following procedure:

1) laparoscopic vertical-banded gastroplasty

2) open-sleeve gastrectomy

3) laparoscopic-sleeve gastrectomy

4) open adjustable gastric banding.

ICD-9-CM Codes

Coverage for selected bariatric surgery procedures on patients who meet national and local coverage criteria are to be reported with

ICD 278.01 (morbid obesity) as a primary diagnosis along with any of the following ICD's

V85.35 BODY MASS INDEX 35.0-35.9, ADULT

V85.36 BODY MASS INDEX 36.0-36.9, ADULT

V85.37 BODY MASS INDEX 37.0-37.9, ADULT

V85.38 BODY MASS INDEX 38.0-38.9, ADULT

V85.39 BODY MASS INDEX 39.0-39.9, ADULT

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