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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

June 2017

Updates to Bariatric Surgeries Medical Review Criteria


Harvard Pilgrim is updating our commercial and StrideSM (HMO) Medicare Advantage medical review criteria for bariatric surgeries. Harvard Pilgrim covers certain bariatric surgeries that are considered medically necessary for morbidly obese adult and adolescent (over 15 years of age) members of our commercial plans, and for morbidly obese Stride members, with prior authorization, when all specified coverage criteria have been met.
 
Effective for dates of service beginning July 1, 2017, we will no longer cover the following procedure codes, as they are considered experimental/investigational:

  • 43842 — Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty
  • 43843 — Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty
The updated policies also include additional procedure-specific information and updates to criteria and coverage exclusions.
 
For more information, and for complete coverage criteria and exclusions, please refer to Harvard Pilgrim’s updated commercial Bariatric Surgeries Medical Review Criteria and StrideSM (HMO) Medicare Advantage Bariatric Surgeries Medical Review Criteria.

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