Anthem Blue Cross Blue Shield of California 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 Blue Shield of California policy (policy CG-SURG-83). It lists 27 CPT or HCPCS codes, 27 of them on the Anthem Blue Cross Blue Shield of California prior authorization list. Not a coverage decision; the payer's own document governs.
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- 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 Blue Shield of California prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of California 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; with gastrojejunostomy (Billroth II) [when specified as bariatric surgery] | Policies naming 43632 |
| 43633 | On the list | Gastrectomy, partial, distal; with Roux-en-Y reconstruction [when specified as bariatric surgery] | Policies naming 43633 |
| 43644 | On the list | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) | Policies naming 43644 |
| 43645 | On the list | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption | Policies naming 43645 |
| 43659 | On the list | Unlisted laparoscopy procedure, stomach [when specified as gastric plication (laparoscopic greater curvature plication [LGCP]) with or without gastric banding, sleeve gastroplasty, or mini-gastric bypass procedure] | Policies naming 43659 |
| 43770 | On the list | Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g., gastric band and subcutaneous port components) | 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 component only | Policies naming 43773 |
| 43774 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components | Policies naming 43774 |
| 43775 | On the list | Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy) | Policies naming 43775 |
| 43842 | On the list | Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty | Policies naming 43842 |
| 43843 | On the list | Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty | Policies naming 43843 |
| 43845 | On the list | Gastric restrictive procedure with partial gastrectomy, pylorus- preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) | Policies naming 43845 |
| 43846 | On the list | Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy | Policies naming 43846 |
| 43847 | On the list | Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption | Policies naming 43847 |
| 43848 | On the list | Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) | 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 | On the list | Gastric restrictive procedure, transoral, endoscopic sleeve gastroplasty (ESG), including argon plasma coagulation, when performed | Policies naming 43889 |
| 43999 | On the list | Unlisted procedure, stomach [when specified as bariatric arterial embolization, endoluminal gastric restrictive surgery, placement of intragastric balloon device, or aspiration therapy] or [when specified as transendoscopic (peroral) gastric myotomy G-POEM] | Policies naming 43999 |
| 64999 | On the list | Unlisted procedure, nervous system [when specified as implantation, revision, replacement, or removal of vagus nerve blocking neurostimulator electrode array or pulse generator at the esophagogastric junction] or [when specified as percutaneous neuromodulation therapy] or [when specified as introduction of Kebilidi into cranial cavity and brain] or [when specified as craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebellar] or [when specified as percutaneous decompression or laser procedures of cervical or thoracic spine] or [when specified as epiduroscopy] or [when specified as pulsed radiofrequency treatment] or [when specified as cooled or pulsed RF therapy (not destruction) to genicular nerve(s)] or [when specified as cryoneurolysis] or [when specified as nanoparticle thermal ablation] or [when specified as adrenal tissue, fetal mesencephalic tissue or fetal xenograft tissue transplant to brain] or [when specified as harvesting or administration of stem cells for therapy to repair damaged cells or body tissues] | Policies naming 64999 |
| C9785 | On the list | Gastric restrictive procedure, endoscopic sleeve gastroplasty, with esophagogastroduodenoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components | Policies naming C9785 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list