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 | * The following article was archived on 06/23/2010.
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Sleeve Gastrectomy
Posted: 01/04/2010 | |
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| Effective January 1, 2010, for Commercial Products as a risk reduction strategy for individuals who are morbidly obese, consideration for sleeve gastrectomy surgery (laparoscopic or open) will be given to individuals who are 18 years of age or older when all of the following criteria are met:
- The individual has a Body Mass Index (BMI) greater than or equal to 50
- It is anticipated that the individual will achieve weight loss and a decrease in comorbidities as a result of the first-stage procedure (sleeve gastrectomy) that allows for the performance of a second-stage bariatric surgery procedure (eg, duodenal switch, Roux-en-Y)
- The planned second-stage bariatric surgery procedure (eg, duodenal switch, Roux-en-Y) is to occur within 24 months following the sleeve gastrectomy procedure.
- The individual has documentation of a failed history of medical weight loss
- The individual is not currently pregnant and/or breast feeding and has agreed to avoid pregnancy for at least one year postoperatively
- The individual has participated in preoperative care that includes all of the components noted below. Preoperative surgical care can be directed and provided by the member's professional provider or through a multi-disciplinary surgical preparatory regimen, which is typically based at facilities that are either certified by the American College of Surgeons (ACS) as a Level 1 Bariatric Surgery Center (program standards and requirements effective February 15, 2006) or by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (BSCOE) (program standards and requirements effective February 15, 2006):
- A thorough medical history and physical examination
- Consultation and instruction by a professional provider on low calorie diets and an exercise program based on the individual's capability
- An evaluation by a licensed mental professional provider that specifically evaluates: any mental health or substance abuse condition; the emotional readiness and ability of the individual to make and sustain lifestyle changes; and the adequacy of their support system
Sleeve gastrectomy for adolescents is considered experimental/investigational and, therefore, not covered because the safety and/or efficacy of this service cannot be established by review of the available published peer-reviewed literature.
Sleeve gastrectomy for Medicare Advantage Products, per original Medicare, is considered experimental/investigational.
To bill for laparoscopic sleeve gastrectomy procedures report:
43775: Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy)
To bill for an open sleeve gastrectomy procedure report:
43999: Unlisted procedure, stomach
About Sleeve Gastrectomy
Sleeve gastrectomy (laparoscopic or open) is a surgical weight-loss procedure in which the stomach is reduced approximately 35 percent of its original size by surgical removal of a large portion of the stomach. The open edges are then attached together (often with surgical staples) to form a sleeve or tube with a banana-type shape. The procedure permanently reduces the size of the stomach. Sleeve gastrectomy was developed as a first-stage in a two-staged procedure in high-risk individuals with a BMI of greater than 60. The theory behind two-staged procedures is that by first performing a procedure such as a laparoscopic sleeve gastrectomy in high-risk, morbidly-obese individuals, followed by a second procedure such as a gastric bypass or a biliopancreatic diversion/duodenal switch, complications and mortality can be reduced due to the significant weight loss provided as a result of the earlier procedure.
There has been a continuous increase in the evidence in the literature supporting the main purpose of sleeve gastrectomy in a two-staged procedure, which is surgical risk reduction in the short-term for the super and super-super-obese patient populations. Resolution of co-morbidities and improvement in risk status due to reduction in the BMI level related to the second-stage surgical procedure (eg, a duodenal switch) have been documented in the short-term for many individuals who underwent laparoscopic sleeve gastrectomy as the first-stage procedure in a staged bariatric surgical approach.
Sleeve gastrectomy has also more recently been used as a stand-alone procedure. However, the key limitation with the majority of the available data on the stand-alone procedure is the lack of long-term (ie, greater than 5 years) follow-up with only a handful of heterogeneously conducted studies that have reported a follow-up beyond 24 months. The role of sleeve gastrectomy as a stand-alone procedure needs to be explored further, as there are a number of established procedures available with sufficient evidence of long-term weight loss. In the absence of reliable data showing long-term efficacy, issues such as weight regain, resurfacing of comorbidties, and having to undergo another bariatric procedure due to potential gastric sleeve dilation remain distinct possibilities for patients that undergo sleeve gastrectomy as a standalone procedure.
If you have any questions, contact your Network Coordinator.
Policy impacted: 11.03.02g Bariatric Surgery
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