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ICD-10-CM Z68.51, Body mass index [BMI] pediatric, less than 5th percentile for age | No Prior Auth

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`Z68.51`, Body mass index [BMI] pediatric, less than 5th percentile for age

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Key Coverage Criteria

Gastric bypass and gastric restrictive procedures are consideredmedically necessarywhenallof the following criteria are met:
Individual is age 18 years or older;and
The recommended surgery is one of the following procedures:Biliopancreatic bypass with duodenal switch;orEndoscopic sleeve gastroplasty;orLaparoscopic adjustable gastric banding;orRoux-en-Y procedure up to 150 cm;orSingle anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S);orDuodenal jejunal bypass with gastric sleeve (DJB-SG);orSleeve gastrectomy;and
Biliopancreatic bypass with duodenal switch;or
Endoscopic sleeve gastroplasty;or
Laparoscopic adjustable gastric banding;or

1 Active Policy

ANTHEM-CG-SURG-83, Bariatric Surgery and Other Treatments for Clinically Severe Obesity

Related Codes

37242(1 policies)43290(1 policies)43291(1 policies)43632(1 policies)43633(1 policies)43644(1 policies)43645(1 policies)00797(1 policies)

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