"When Covered" section revisions: 

Section A:  Criteria for Adults....A.1.b. have a BMI > 35 associated with at least one or more of the following problems which are generally expected to be improved, curtailed or reversed by surgical treatment:  Revisions underA.1.b:  iiThe obesity causes incapacitating pain and limitation of motion in any weight-bearing joint or the lumbosacral spine documented by physical examination in association with radiologic findings showing degenerative osteoarthritis; iii. There is significant respiratory insufficiency as evidenced by pCO2 > 50 mmHg, hypoxemia at rest, as evidenced by pO2 < 55 mmHg on room air; FEV1/FVC < 65%, or DLCO < 60% (e.g., Obesity Hypoventilation Syndrome); iv. Clinically significant obstructive sleep apnea (i.e., Patient meets criteria for treat­ ment of obstructive sleep apnea set forth in policy number OTH8138, titled Sleep Apnea and Breathing Related Sleep Disorders in Adults);  v. Type 2 diabetes mellitus; vi. Documented coro­nary artery disease; vii. Cardiomyopathy; viii. Heart failure; ix.Gastroesophageal reflux disease with secondary asthma or erosive esophagitis not controlled despite maximum dosages of proton pump inhibitors; x. Pseudotumor cerebri; xi. Patient has at least one of the following: Medically refractory hypertension (blood pressure > 140 mmHg systolic and/or > 90 mmHg diastolic mea­sured with appropriate size cuff) that has not responded to medical management including at least two (2) anti-hypertensive drugs at maximum tolerated dosages; First degree relative with prema­ture (age < 50) cardiovascular disease; Hypercholesterolemia > 240 mg/dL or hypertriglyceri­demia > 400 mg/dL or low density lipoprotein (LDL) >160 mg/dL or high density lipoprotein (HDL) < 40 mg/dL;  despite appropriate medical therapy defined as at least one appropriate drug at maximum dosage; Metabolic syndrome; Pulmonary hypertension.  A.4. has been deleted "Patient has achieved full growth (for adolescents bone age shows closure of epiphyseal plates.

Section B. is now "Criteria for Adolescents < 18 years of age:  Coverage for adolescents under 18 years of age may be provided only in a covered clinical trial offering a multidisciplinary team approach capable of managing the unique challenges posed by the adolescent age group.  For the purpose of this policy, severe adolescent morbid obesity is considered a life threatening condition.  Refer to Clinical Trial policy (MED1093) for other criteria a covered clinical trial must meet.

Section C. is now "Surgical Procedures" (changed from B. to C.).  C.1. Will now be "Short limb Roux-en-Y" (moved from end to beginning of C.1); C.2. Will now be "Long limb Roux-en-Y" (moved from end to beginning of C.2); Deleted C.3.b. BMI <50 (Patients with BMI >50 need a pro­cedure to achieve greater weight loss.  Thus the use of adjustable gastric banding, which results in less weight loss, should be most useful as one of the procedures used for patients with BMI <50.)

Section D. is now Surgical Revision (changed from C. to D. and deleted "Reoperation and"; D.2.o. Deleted "Disrupted staple line provided there has been prior weight loss".  D.2.o. is now "Intracta­ble ulcer". "When Not Covered" section revisions:
2.d. Adjustable Gastric Banding: Deleted d.ii. in patients with a BMI >50.  Added 2.k. "Endoscopic procedures (e.g., insertion of the StomaphyXTM device) to treat weight gain after bariatric surgery to remedy large gastric stoma or large gastric pouches."

"Policy Guidelines" section revisions:

# 3 now reads "Within 12 months prior to surgery, a thorough nutritional evaluation by a physician or registered dietician experienced in the issues of bariatric surgery, who has had a meaningful conversation with the individual regarding the dietary and lifestyle changes required to ensure a successful outcome over time."

#4 now reads "Evaluation by a licensed psychologist or psychiatrist that documents the absence of significant psychopathology that can limit the patient’s understanding of  the procedure or the ability to comply with medical/surgical recommendations and to adhere to required lifestyle modi­fications and follow up/social support. Psychologist/Psychiatrist must document the patient's suit­ability for the proposed bariatric surgery and the lifetime commitment required for a successful outcome.

#5 now reads "Appropriate medical work up may include a chest x-ray, upper gastrointestinal series, endoscopy, appropriate pre-op labs and ECG. A complete physical examination by the attending surgeon and an assessment of thyroid levels is required.  If the patient has comorbid con­ditions (e.g. diabetes or cardiovascular disease) the patient must be capable of undergoing the pro­cedure.
Statement under #6 now reads "The first five criteria must be met before seeking prior plan approval, the sixth must be met prior to surgery."
Description section revised.  Medical term definitions and Reference sources added. 

Notification given 10/6/08.  Effective date 1/5/2009.

Revisions under "When Covered" section  B.  Now reads "Complications of a surgically created wound (e.g., dehiscence) or a traumatic wound (e.g., pre-operative flap or graft) when the following criteria are met. 1) Coverage may be provided only if a conventional wound therapy program has been tried and failed or if the patient has a contraindication to a conventional wound therapy program.  Documentation must be pro­vided (see Billing/Coding/Physician Documentation Information section). 2) Need for accelerated formation of granulation tissue which cannot be achieved by other available topical wound treat­ments because of the unique nature of the wound.  3) There is risk or co-morbidity present expected to significantly prolong healing achievable with other topical wound treatments."

Revisions under "When Not Covered" section:
3. Now reads "Vacuum-Assisted Closure of surgically created wounds or traumatic wounds is not covered if the criteria under "When Covered" section, B.1-3 is not met."

Revisions under "Policy Guidelines" section:
B. Surgically Created or Ttraumatic Acute and subacute Wwounds: 
1) Coverage may be provided only if a conventional wound therapy program has been tried and failed or if the patient has a contraindication to a conventional wound therapy program.  Docu­mentation must be provided.  Vacuum-assisted closure Wound vacs will not be approved as pri­mary treatment........
C. Continued Coverage for Wounds Described Above:  Vacuum-assisted closure may be.....
Other:

Revisions under "When Covered" section:
A.1.a. Varicose vein ligation and excision (VVLE/varicose vein ligation and stripping (VVLS) for treatment of GSV, LSV, or accessory vein reflux.
A.2. added "accessory saphenous vein" to list of"all proximal sources of reference
 A. Note-added "and coverage of microphlebectomy is limited to one session per leg"; added reticu­lar veins to list "Sclerotherapy coverage does not include treatment of......"; added (GSV, LSV, or accessory saphenous vein)  following "saphenous vein" in next to last sentence.
B.7. Now reads: "Procedure (CPT) codes for proposed interventions specifying the vein(s) to be treated with each procedure (e.g. GSV, LSV, accessory saphenous vein, perforator, varicose tribu­taries, reticular veins, spider veins, telangiectasia) and whether Left, Right, or Bilateral; and for sclerotherapy also stating the number of sessions for each leg."

Revisions under "When Not Covered" section:

3. Added "or accessory saphenous vein" to investigational list.
7. Added "or more than one session of microphlebectomy per leg".
Added 9. "Surgical removal, EVLT, and/or ERFA can be performed safely and effectively on multi­ple veins of the same leg as part of a single surgery.  Therefore, staging of surgical procedures on different dates of service to treat more than one incompetent saphenous vein (GSV, LSV, accessory saphenous vein) in the same leg is considered to be not medically necessary."

Other:
Reference sources added.  Specialty Matched Consultant Advisory Panel review - 9/4/08. 
Notification given 10/6/08.  Effective date 1/5/09