11.03.02x, Bariatric Surgery

REQUIREMENTS: - By 03/17/2026: Billing team must update billing system and encounter forms to reflect SADI-S/SIPS procedures (newly reclassified as Medically Necessary) and remove coverage denials for these procedures. Remove HCPCS code C9784 from all billing logic and claims scrubbing rules immediately (retroactive to 01/01/2026). Add HCPCS code C9785 to experimental/investigational category requiring pre-service medical review before claim submission. - Before 03/17/2026: Update prior authorization workflows to recognize SADI-S/SIPS as covered procedures under the medically necessary criteria outlined in the policy (BMI thresholds, comorbidities, documented weight loss attempts, preoperative evaluation requirements). Modify claim edits to enforce all coverage criteria: BMI verification, failed conservative weight loss documentation, behavioral intervention program participation, pregnancy/breastfeeding status verification, and preoperative surgical preparation compliance. - Immediately: Review current claims in queue with HCPCS code C9784 and C9785; reprocess C9784 denials or route to compliance review. Flag any C9785 claims as experimental/investigational pending medical review. - Provider notification: Communicate to bariatric surgery providers that SADI-S/SIPS are now covered (no longer experimental) effective 03/17/2026, and that new experimental procedures (natural orifice transoral endoscopic surgery and code C9785) require pre-authorization. Provide updated medical necessity criteria checklist.