BARIATRIC SURGERY - Health Plan of Nevada
BARIATRIC SURGERY - Health Plan of Nevada
BARIATRIC SURGERY - Health Plan of Nevada
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• Adjustable gastric banding (laparoscopic adjustable silicone gastric banding)<br />
• Gastric sleeve procedure (also known as laparoscopic vertical gastrectomy or laparoscopic<br />
sleeve gastrectomy)<br />
• Vertical banded gastroplasty (gastric banding; gastric stapling)<br />
• Biliopancreatic bypass (Scopinaro procedure)<br />
• Biliopancreatic diversion with duodenal switch<br />
Robotic assisted gastric bypass surgery is medically necessary non-preferentially for use in bariatric<br />
surgery.<br />
Surgical revision or a second bariatric surgery is medically necessary for inadequate weight loss if<br />
the original criteria for bariatric surgery (BMI, co-morbidities and patient selection criteria) continue to<br />
be met.<br />
Surgical revision <strong>of</strong> bariatric surgery is medically necessary for complications <strong>of</strong> the original<br />
surgery, such as stricture, obstruction, pouch dilatation, erosion, or band slippage when the<br />
complication causes abdominal pain, inability to eat or drink or causes vomiting <strong>of</strong> prescribed meals.<br />
Bariatric surgical procedures in a person who has not attained an adult level <strong>of</strong> physical<br />
development and maturation are not medically necessary. Potential safety issues must be addressed<br />
in studies with sufficient sample size and adequate follow-up times necessary to demonstrate the<br />
impact <strong>of</strong> the surgery on physical, sexual and reproductive maturation and the long term improvement<br />
<strong>of</strong> co-morbidities in this age group.<br />
Transoral endoscopic surgery (such as transoral gastroplasty [TOGA®], StomaphyX, and<br />
Restorative Obesity Surgery, Endoluminal [ROSE] procedure) is not medically necessary as a<br />
treatment for obesity. The medical device used for TOGA has not received FDA approval. A clinical<br />
trial is currently underway to evaluate the safety and effectiveness <strong>of</strong> TOGA. Further studies are<br />
needed to determine the safety and efficacy <strong>of</strong> StomaphyX and the Rose procedure for the revision <strong>of</strong><br />
gastric bypass surgery to reduce the stomach pouch and stomach outlet (stoma) to the original gastric<br />
bypass size.<br />
The mini-gastric bypass (MGB), also known as laparoscopic mini-gastric bypass (LMGBP) is not<br />
medically necessary. Further studies are needed to determine the safety and efficacy <strong>of</strong> mini-gastric<br />
bypass surgery. In addition, patient selection criteria must be better defined for this procedure.<br />
Gastric electrical stimulation with an implantable gastric stimulator (IGS) is not medically<br />
necessary. Further studies are needed to determine the safety and efficacy <strong>of</strong> gastric electrical<br />
stimulation with an implantable gastric stimulator as an option for treating obesity with bariatric<br />
surgery.<br />
Intragastric balloon is not medically necessary as a treatment for obesity. Further studies are needed<br />
to determine the safety and efficacy <strong>of</strong> intragastric balloon as a treatment option for obesity.<br />
Gastrointestinal liners (EndoBarrier) are not medically necessary as a treatment for obesity. The<br />
use <strong>of</strong> gastrointestinal liners has not received FDA approval.<br />
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