and more............
http://mcgs.bcbsfl.com/ THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION. Non-Covered Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines Other References Updates DESCRIPTION:
In cases where a severe, potentially life threatening condition develops which is documented in the medical record, gastric bypass revision is considered medically necessary and may be eligible for coverage.
WHEN SERVICES ARE COVERED:
The following lists examples of conditions
AND/OR diagnoses for which gastric bypass revisions may be covered:
- <LI class=bulletedList-1>Weight loss of 20% or more below the ideal body weight (based on the 1996 Metropolitan Life Height & Weight tables Men and Women) <LI class=bulletedList-1>Esophagitis (e.g., esophageal reflux) <LI class=bulletedList-1>Hemorrhage or hematoma complicating a procedure <LI class=bulletedList-1>Vomiting (bilious) following gastrointestinal surgery <LI class=bulletedList-1>Gastrointestinal complications, (i.e., complications of intestinal (internal) anastomosis and bypass) <LI class=bulletedList-1>Stomal dilatation, documented by endoscopy (not UGI) <LI class=bulletedList-1>Pouch dilation documented by upper gastrointestinal examination or endoscopy, producing weight gain of 20% or more <LI class=bulletedList-1>Stomal stenosis after vertical banding, documented by endoscopy, producing vomiting or weight loss of 20% or more <LI class=bulletedList-1>Other and unspecified post surgical nonabsorption (i.e., hypoglycemia and malnutrition following gastrointestinal surgery) <LI class=bulletedList-1>Other post-operative functional disorders (i.e., diarrhea following gastrointestinal surgery), <LI class=bulletedList-1>Severe dumping syndrome <LI class=bulletedList-1>Post-gastric surgery syndromes (i.e., post-gastrectomy syndrome, post-vagotomy syndrome) <LI class=bulletedList-1>Disruption of operation wound <LI class=bulletedList-1>Staple line failure, documented by upper gastrointestinal examination
- Disrupted staple line provided there has been prior weight loss.
WHEN SERVICES ARE NOT COVERED:
Gastric bypass revision services are not covered when coverage criteria are not met as described in the
WHEN SERVICES ARE COVERED section or when the member's contract does not provide benefits for these services.
BILLING/CODING INFORMATION: CPT Coding:
43848
Revision
, open, of gastric restrictive procedure for morbid obesity,
other than adjustable gastric band (separate procedure)
43850
Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; without vagotomy
43855
Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; with vagotomy
43860
Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy
43865
Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy
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 ICD-9 Diagnoses Codes That Support Medical Necessity:
530.1
Esophagitis (esophageal reflux)
536.1
Acute dilatation of stomach (documented by endoscopy, not UGI)
536.1
Pouch dilation (documented by UGI or endoscopy; producing weight gain of 20% or more)
537.6
Stenosis of stomach (after vertical banding documented by endoscopy; producing vomiting or weight loss of 20% or more)
564.2
Postgastric surgery syndrome (i.e., post-gastrectomy syndrome, post-vagotomy syndrome, severe dumping syndrome)
564.3
Vomiting following gastrointestinal surgery
564.4
Other post-operative functional disorders (i.e., diarrhea following gastrointestinal surgery)
579.3
Other and unspecified postsurgical nonabsorption (i.e., hypoglycemia, malnutrition following gastrointestinal surgery)
783.2
Abnormal loss of weight (20% or more below the ideal body weight according to the 1996 Metropolitan Life Height & Weight tables for men and women)
997.4
Digestive system complications (i.e., complications of intestinal (internal) anastomosis and bypass)
998.11-998.13
Hemorrhage or hematoma complicating a procedure
998.3
Disruption of operation wound (i.e., dehiscence; rupture; staple line failure documented by upper gastrointestinal examination; disrupted staple line, provided there has been prior weight loss)
REIMBURSEMENT INFORMATION:
Refer to section entitled
WHEN SERVICES ARE COVERED.
PROGRAM EXCEPTIONS: Federal Employee Program (FEP): Follow FEP guidelines.
State Account Organization (SAO): Follow SAO guidelines.
DEFINITIONS:
No guideline specific definitions apply.
RELATED GUIDELINES: Surgery for Clinically Severe Obesity (Bariatric Surgery; Gastric Bypass Surgery), 02-40000-10 OTHER:
To view the Metropolitan Life Height & Weight tables Men and Women, see
Surgery for Clinically Severe Obesity (Gastric Bypass), 02-4000-10.
REFERENCES: - <LI value=1>American Medical Association CPT (current edition) <LI value=2>Florida Medicare Part B Local Medical Review Policy # 11920: Cosmetic/Reconstructive Surgery (01/01/02, retired 02/01/04) <LI value=3>Florida Medicare Part B Local Medical Review Policy # 40000: Digestive System (01/01/02) <LI value=4>Medical Practice and Coverage Committee (BCBSF)
- St. Anthony’s ICD-9-CM Code Book (current edition)
COMMITTEE APPROVAL:
This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 09/23/04.
GUIDELINE UPDATE INFORMATION:
10/15/99
New Medical Coverage Guideline.
01/01/02
Coding changes.
12/15/02
Reviewed; typographical corrections.
10/15/04
Scheduled review; no change in coverage statement; added 43848.
01/01/06 Annual HCPCS coding update (revise 43848; add 43886, 43887, and 43888. Private Property of Blue Cross and Blue Shield of Florida.
This medical coverage guideline is Copyright 2006, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2006 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association.
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Date Printed: January 5, 2007: 10:48 PM
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