L29317-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Surgical Management of Morbid Obesity (L29317)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29317

LCD Title

Surgical Management of Morbid Obesity

Contractor's Determination Number 43644

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 01/01/2011

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-2, Medicare Benefit Policy Manual, Chapter 16, Section 120

Program Memorandum, Transmittal 23 (CR 3502)

CMS Manual System, Pub. 100-3, Medicare National Coverage Determinations, Chapter 1, Part 2, Section 100.1 Change Request 4399, Transmittal 889, March 17, 2006

Change Request 5013, Transmittal 931, April 28, 2006

CMS Manual System, Pub. 100-4, Medicare Claims Processing Manual, Chapter 32, Section 150

Indications and Limitations of Coverage and/or Medical Necessity

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.

Medicare will consider surgical management for the treatment of morbid obesity reasonable and necessary when ALL of the following conditions are met:

• The patient meets the definition of morbid obesity which is defined as a body mass index (BMI) > 35 and comorbid conditions exist (eg . hypertensive cardiovascular disease, pulmonary/respiratory disease, diabetes, sleep apnea or degenerative arthritis of weight-bearing joints). Documentation of the level of severity of the comorbid existing condition must be included in the patient’s medical record; AND

• The patient has been previously unsuccessful with medical treatment for obesity; AND

• Treatable metabolic causes for obesity (e.g., adrenal or thyroid disorders) have been ruled out or have been clinically treated if present; AND.

• When performed at facilities that are (1) certified by the Amercian College of Surgeons as a Level I Bariatric Surgery Center (program standards and requirements in effect on February 15, 2006); or (2) certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (program standards and requirements in effective on February 15, 2006). A list of approved facilites and their approval dates will be listed and maintained on the CMS coverage website @ http://www.cms.hhs.gov/coverage, and will be published in the Federal Register.

There is not sufficient data published in the medical literature to draw conclusions about the safety and effectiveness of the following surgical techniques and they would therefore be considered investigational and noncovered when performed for severe obesity:

• Adjustable gastric banding (i.e., Lap-Band Adjustable Gastric Banding System). (CPT code 43843)

• Long Limb Gastric Bypass (i.e., more than 100cm) (CPT code 43999)

• Mini-Gastric Bypass (CPT code 43999) CPT code 43846 does not accurately describe the mini-gastric bypass. The Rouy-en-Y gastroenterostomy is not used in the mini-gastric bypass.

• Open sleeve gastrectomy, laparoscopic vertical banded gastroplasty and open adjustable gastric banding (CPT code 43999)

CPT code 43842 (Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertcal-banded gastroplasty) is non-covered for Medicare effective for services performed on or after February 21, 2006.

The following procedures are associated with the above surgical techniques that are considered investigational and non-covered when performed for severe obesity. Therefore, they are also considered investigational and non- covered.

43659 Unlisted laparoscopy procedure, stomach (non-covered when billed for the removal and replacement of both gastric band and subcutaneous port components)

43886 Gastric restrictive procedure, open; revision of subcutaneous port component only 43887 removal of subcutaneous port component only

43888 removal and replacment of subcutaneous port component only

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

CPT code 43659 (Unlisted laparoscopy procedure, stomach) is non-covered when billed for the removal and replacement of both gastric band and subcutaneous port components.

CPT codes 43770, 43771, 43772, 43773, 43774, 43845, 43847, are covered for services performed on or after

February 21, 2006.

CPT code 43842 is non-covered for services performed on or after February 21, 2006. CPT codes 43843, 43886, 43887, 43888, 43999 are noncovered.

43644 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND ROUX-EN-Y GASTROENTEROSTOMY (ROUX LIMB 150 CM OR LESS)

43645 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION

43659 UNLISTED LAPAROSCOPY PROCEDURE, STOMACH

43770 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS)

43771 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REVISION OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY

43772 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY

43773 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL AND REPLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY

43774 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS

43842 GASTRIC RESTRICTIVE PROCEDURE, WITHOUT GASTRIC BYPASS, FOR MORBID OBESITY; VERTICAL- BANDED GASTROPLASTY

43843 GASTRIC RESTRICTIVE PROCEDURE, WITHOUT GASTRIC BYPASS, FOR MORBID OBESITY; OTHER THAN VERTICAL-BANDED GASTROPLASTY

GASTRIC RESTRICTIVE PROCEDURE WITH PARTIAL GASTRECTOMY, PYLORUS-PRESERVING

43845 DUODENOILEOSTOMY AND ILEOILEOSTOMY (50 TO 100 CM COMMON CHANNEL) TO LIMIT ABSORPTION (BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH)

43846 GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID OBESITY; WITH SHORT LIMB (150 CM OR LESS) ROUX-EN-Y GASTROENTEROSTOMY

43847 GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID OBESITY; WITH SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION

43848 REVISION, OPEN, OF GASTRIC RESTRICTIVE PROCEDURE FOR MORBID OBESITY, OTHER THAN ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (SEPARATE PROCEDURE)

43886 GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY

43887 GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL OF SUBCUTANEOUS PORT COMPONENT ONLY

43888 GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL AND REPLACEMENT OF SUBCUTANEOUS PORT COMPONENT ONLY

43999 UNLISTED PROCEDURE, STOMACH

ICD-9 Codes that Support Medical Necessity

For procedure codes 43644, 43645, 43770 (for services performed on or after February 21, 2006), 43845 (for services performed on or after February 21, 2006), 43846 and 43847 (for services performed on or after February 21, 2006).

278.01 MORBID OBESITY

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

V85.41 - V85.45* BODY MASS INDEX

40.0-44.9, ADULT - BODY MASS INDEX 70 AND OVER, ADULT

* According to the ICD-9-CM book, diagnosis codes identified with asterisks are secondary diagnosis codes and should not be billed as the primary code.

For procedure codes 43659 and 43842 (for services performed prior to February 21, 2006)

278.01 MORBID OBESITY

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Claims for surgical procedures for clinically severe obesity will be reviewed on a prepayment basis. All claims for this procedure must include the following documentation: history and physical containing evidence of comorbid conditions, operative report containing a detailed procedure note, office/progress notes documenting unsuccessful medical treatment for obesity.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Sources of Information and Basis for Decision

Bariatric Surgery: American Society for Bariatric Surgery Guidelines retrieved from http://www.lapsurgery.com on April 10, 2007.

Brolin R E. Bariatric surgery and long-term control of morbid obesity. JAMA 2002 Dec; 288(22):2793-2796. National Institute of Health. Bariatric Surgery Clinical Research Consortium, November 1, 2002

2004 American Society for Bariatric Surgery Consensus COnference, Consensus conference statement bariatric surgery for morbid obesity: Health implications for patients, health professionals and third party payor.

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was

developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 01/01/2011

Revision History Number 3

Revision History Explanation Revision Number:3 Start Date of Comment Period:N/A

Start Date of Notice Period:01/01/2011 Revised Effective Date: 01/01/2011

LCR B2011-005

December 2010 Update

Explanation of Revision: Annual 2011 HCPCS Update. CPT code 43775 was deleted as it is nationally noncovered. The effective date of this revision is based on date of service.

Revision Number:2

Start Date of Comment Period:N/A Start Date of Notice Period:10/01/2010 Revised Effective Date: 10/01/2010

LCR B2010-071

September 2010 Update

Explanation of Revision: Annual 2011 ICD-9-CM Update. Deleted ICD-9-CM code V85.4. Added new ICD-9-CM codes V85.41-V85.45. for CPT codes 43644, 43645, 43770, 43845, 43846 and 43847. The effective date of this revision is based on date of service.

Revision Number:1

Start Date of Comment Period:N/A Start Date of Notice Period:01/01/2010 Revised Effective Date: 01/01/2010

LCR B2010- 005

December 2009 Update

Explanation of Revision: Annual 2010 HCPCS Update. Added CPT code 43775 as non-covered. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-044FL

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29317) replaces LCD L14600 as the policy in notice. This document (L29317) is effective on 02/02/2009.

09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update.

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

43659 descriptor was changed in Group 1 43886 descriptor was changed in Group 1 43887 descriptor was changed in Group 1 43888 descriptor was changed in Group 1

Reason for Change