43820 Insurance Policy Changes

CPT 43820, in plain terms, covers Surgeon creates an anastomosis between the stomach and jejunum without vagotomy. CPT 43820 is referenced in 2 tracked payer policy changes from Regence BlueShield. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 43820 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Official descriptor: CPT 43820 on AAPC

Regence BlueShield · Effective Apr 1, 2026Medium impact
Gastroesophageal Reflux Surgery
Initial esophagogastric fundoplication for symptomatic gastroesophageal reflux disease may be considered medically necessary when no paraesophageal hiatal hernia repair is requested or documented, symptoms are unresponsive to lifestyle modifications, a medication requirement is met (a 4-month total trial of proton pump inhibitors that is ineffective, contraindicated or not tolerated, or PPIs used for 12 or more consecutive months within the past 18 months with surgery considered an alternative to long-term medication), and reflux is objectively confirmed by endoscopy or, if endoscopy is normal, by 24-hour ambulatory esophageal pH monitoring or barium swallow. Fundoplication may also be considered medically necessary for children and adolescents age 17 or younger, for individuals with pulmonary fibrosis and symptomatic or asymptomatic reflux, for a confirmed paraesophageal hiatal hernia (Types II-IV), for esophageal myotomy in achalasia, and for repeat fundoplication after a documented mechanical failure. Gastrectomy, gastrojejunostomy as a stand-alone treatment, and hiatal hernia repair without fundoplication are considered investigational for gastroesophageal reflux.
Regence BlueShield · Effective Feb 1, 2026Medium impact
Bariatric Surgery
Medical Policy SUR58, Bariatric Surgery, has an effective date of February 1, 2026. Bariatric surgery may be considered medically necessary for obesity when the patient has a BMI of 40 or greater, or a BMI of 35 or greater with type II diabetes, poorly controlled hypertension despite optimal medical management, coronary artery disease, or obstructive sleep apnea with an AHI of 15 or more per hour, and the patient is 18 or older (or under 18 with Tanner 4 or 5 development and the pediatric BMI thresholds in the policy). Patients must have at least 3 consecutive months of active participation in a structured, medically supervised pre-operative program within the 12 months before the surgery request, and a preoperative evaluation by a licensed psychologist, psychiatrist, LCSW/LICSW, licensed masters-level counselor or PMHNP must document the absence of significant psychopathology. Medically necessary procedures are a stand-alone sleeve gastrectomy, gastric bypass with a Roux-en-Y anastomosis and an alimentary limb of 150 cm or less, and biliopancreatic bypass with duodenal switch for patients 18 or older with a BMI of 50 or greater; vertical banded gastroplasty and adjustable gastric banding are not medically necessary, and distal gastric bypass, mini-gastric bypass, endoscopic bariatric procedures, gastric plication and two-stage procedures are investigational.

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REFERENCE DATA

Payers with rules2

Payers requiring prior auth2

CalViva Health · Effective December 31, 2025
Prior authorization required
CalViva Health CMS-0057-F prior authorization requirements
Community Health Plan of Imperial Valley · Effective December 31, 2025
Prior authorization required
Community Health Plan of Imperial Valley CMS-0057-F prior authorization requirements

FREQUENTLY ASKED QUESTIONS

Does CalViva Health require prior authorization for 43820?

CalViva Health lists 43820 on CalViva Health CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does Community Health Plan of Imperial Valley require prior authorization for 43820?

Community Health Plan of Imperial Valley lists 43820 on Community Health Plan of Imperial Valley CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

What insurance policy changes affect CPT 43820?

There are 2 tracked policy changes affecting CPT 43820, including updates from Regence BlueShield. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 43820?

Payers that have issued tracked updates for CPT 43820 include: Regence BlueShield.

How do I get notified when CPT 43820 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 43820. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for CPT 43820?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

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Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for 43820 in one place.

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All billing codes J3590 C9399 J3490 99215 99213 99202

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Gastroesophageal Reflux Surgery

Bariatric Surgery

Prior authorization required