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Issue Number - Name
0008 - Bariatric Surgery
Review Type
Complex
Claim Type
Outpatient Hospital
Region and State
RAC 1-4
All States
Date Approved
2017-02-01

Description

The surgical management for the treatment of morbid obesity is considered reasonable and necessary for Medicare beneficiaries who have a BMI >35, have at least one co-morbidity related to obesity and have been previously unsuccessful with the medical treatment of obesity. Claims reporting surgical services for beneficiaries that do not meet all the Medicare coverage guidelines will be denied as not medically necessary.

Affected Codes

  • 44.39, 44.95, 45.51, 45.91, 43.82, 278.01, 44.38, 43842, 278.01, 43.82, V85.35-V85.45, Z68.35-Z68.45, 250.00-250.92, 43770, 43644, 43845, 43846, 43645, 43847, 43775

Applicable Policy References 

  • Title XVIII of the Social Security Act, Section 1862 (a)(1)(A)
  • CMS Publication 100-03, National Coverage Determinations Manual, Chapter 1, Part 2, Section 100.1 
  • CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 150
  • First Coast LCD, L33411, Effective date 10/1/2015
  • First Coast LCD, L29317, Effective date 02/02/2009, Retired 9/30/2015
  • First Coast LCD, L33019, Effective date 01/29/2013, Retired 9/30/2015
  • NGS LCA, A52447, Effective date 10/01/2015
  • NGS LCA, A51967, Effective date 10/01/2012, Retired 9/30/2015
  • Novitas LCD, L35022, Effective date 10/1/2015
  • Novitas LCD, L32619, Effective date 08/13/2012, Retired 9/30/2015
  • Novitas LCD, L34495, Effective date12/5/2013, Retired 9/30/2015
  • Noridian LCD, L32866, Effective date 3/5/2013, Retired 9/30/2015
  • Noridian LCD, L33362, Effective date 8/26/2013, Retired 9/30/2015
  • Noridian LCD, L33533, Effective date 9/16/2013, Retired 9/30/2015
  • Noridian LCA, A53026, Effective date 10/1/2015
  • Noridian LCA, A53028, Effective date 10/1/2015
  • Noridian LCA, A50227, Effective date 10/20/2008, Retired 9/30/2015
  • Noridian LCA, A52803, Effective date 3/24/2014, Retired 9/30/2015
  • Palmetto GBA LCD, L34576, Effective date 10/1/2015
  • Palmetto GBA LCD, L32975, Effective date 3/11/2013, Retired 9/30/2015
  • WPS LCA, A54923, Effective date 3/1/2016