Anthem Blue Cross and Blue Shield Virginia policy
CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity is a public Anthem Blue Cross and Blue Shield Virginia policy (policy CG-SURG-83). It lists 27 CPT or HCPCS codes, 24 of them on the Anthem Blue Cross and Blue Shield Virginia prior authorization list. Not a coverage decision; the payer's own document governs.
- Policy number
- CG-SURG-83
- Line of business
- Commercial
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross and Blue Shield Virginia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross and Blue Shield Virginia policies |
|---|---|---|---|
| 0813T | On the list | Esophagogastroduodenoscopy, flexible, transoral, with volume adjustment of intragastric bariatric balloon | Policies naming 0813T |
| 43290 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon | Policies naming 43290 |
| 43291 | On the list | Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s) | Policies naming 43291 |
| 43632 | On the list | Gastrectomy, Partial, Distal; W/Gastrojejunostomy | Policies naming 43632 |
| 43633 | On the list | Gastrectomy, Partial, Distal; W/Roux-En-Y Reconstruction | Policies naming 43633 |
| 43644 | On the list | Laparoscopy, Surg, Gastric Restrictive Procedure; W Gastric Bypass And Roux-En-Y Gastroenterostomy (Roux Limb <= 150 Cm) | Policies naming 43644 |
| 43645 | On the list | Laparoscopy, Surgical, Gastric Restrictive Procedure; With Gastric Bypass And Small Intestine Reconstruction | Policies naming 43645 |
| 43659 | Not listed | Policies naming 43659 | |
| 43770 | On the list | Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric ba | Policies naming 43770 |
| 43771 | On the list | Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only | Policies naming 43771 |
| 43772 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only | Policies naming 43772 |
| 43773 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device c | Policies naming 43773 |
| 43774 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous | Policies naming 43774 |
| 43775 | On the list | Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) | Policies naming 43775 |
| 43842 | On the list | Gastric Restrictive Proc, W/O Gastric Bypass, Morbid Obesity; Vertical-Banded Gastroplasty | Policies naming 43842 |
| 43843 | On the list | Gastric Restrictve Proc, W/O Gastric Bypass, Morbid Obesity; Non-Vertical-Banded Gastroplasty | Policies naming 43843 |
| 43845 | On the list | Gastric Stapling Morbid Obesity | Policies naming 43845 |
| 43846 | On the list | Gastric Restrictve Procedre, W/Gastric Bypass, Morbd Obsty; W/Short Limb Roux-En-Y Gastroenterostmy | Policies naming 43846 |
| 43847 | On the list | Gastric Restrictive Proc, W/Gastric Bypass, Morbid Obesity; W/Small Bowel Reconstruction | Policies naming 43847 |
| 43848 | On the list | Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (s | Policies naming 43848 |
| 43886 | On the list | Gastric restrictive procedure, open; revision of subcutaneous port component only | Policies naming 43886 |
| 43887 | On the list | Gastric restrictive procedure, open; removal of subcutaneous port component only | Policies naming 43887 |
| 43888 | On the list | Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only | Policies naming 43888 |
| 43889 | Not listed | Policies naming 43889 | |
| 43999 | On the list | Unlisted Proc, Stomach | Policies naming 43999 |
| 64999 | Not listed | Policies naming 64999 | |
| C9785 | On the list | Endoscopic outlet reduction, gastric pouch application, with endoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components | Policies naming C9785 |
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list