BARIATRIC SURGERY - Health Plan of Nevada

WOU001
The gastric sleeve procedure (also known as laparoscopic vertical gastrectomy or laparoscopic
sleeve gastrectomy) when done alone and not a part of the full operation to complete a
biliopancreatic diversion with duodenal switch (BPDDS or DS) is considered medically necessary in
adults for the treatment of clinically severe obesity as defined by the National Heart Lung and Blood
Institute (NHLBI).
Bariatric surgery is medically necessary for the following:
1. Class III obese (BMI > 40 kg/m 2 ); or
2. Class II obese (BMI 35-39.9 kg/m 2 ) in the presence of one or more of the following
comorbidities:
• Type 2 diabetes; and/or
• Cardiovascular disease (e.g., stroke, myocardial infarction, stable or unstable angina pectoris,
hypertension or coronary artery bypass); and/or
• Life-threatening cardiopulmonary problems (e.g., severe sleep apnea, Pickwickian syndrome,
obesity-related cardiomyopathy).
Surgical revision or a second bariatric surgery is considered medically necessary for inadequate
weight loss if the original criteria for bariatric surgery (BMI, co-morbidities and patient selection criteria)
continue to be met.
Surgical revision of bariatric surgery is considered medically necessary for complications of the
original surgery, such as stricture, obstruction, pouch dilatation, erosion, or band slippage when the
complication causes abdominal pain, inability to eat or drink or causes vomiting of prescribed meals.
Robotic assisted gastric bypass surgery is considered medically necessary if the standard surgical
approaches are shown to be detrimental to the patient.
Natural orifice transluminal endoscopic surgery (i.e., Rose Procedure, StomaphyX) is not medically
necessary for revision of gastric bypass surgery. Further studies are needed to determine the safety and
efficacy of natural orifice transluminal endoscopic surgery for the revision of gastric bypass surgery to
reduce the stomach pouch and stomach outlet (stoma) to the original gastric bypass size.
The mini-gastric bypass (MGB), also known as laparoscopic mini-gastric bypass (LMGBP) is not
medically necessary. Further studies are needed to determine the safety and efficacy of mini-gastric
bypass surgery. In addition, patient selection criteria must be better defined for this procedure.
Gastric electrical stimulation with an implantable gastric stimulator (IGS) is not medically
necessary. Further studies are needed to determine the safety and efficacy of gastric electrical stimulation
with an implantable gastric stimulator as an option for treating obesity with bariatric surgery.
Intragastric balloon is not medically necessary as a treatment for obesity. Further studies are needed to
determine the safety and efficacy of intragastric balloon as a treatment option for obesity.
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