Medicare Coverage for Gastric Sleeve

CMS Considers Coverage of Gastric Sleeve

Medicare Coverage for Gastric SleeveThe Centers for Medicare and Medicaid Services (CMS) said they will consider a proposal to cover laparoscopic sleeve gastrectomy as a treatment for obesity for Medicare beneficiaries.

The agency is requesting public comments to determine “whether there is adequate evidence, including clinical trials, for evaluating health outcomes of laparoscopic sleeve gastrectomy for the indications listed in the current Bariatric Surgery for the Treatment of Morbid Obesity National Coverage Determination.”

Although Medicare has been covering bariatric surgery since 2005, the only procedures currently covered are open and laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and open and laparoscopic biliopancreatic diversion with duodenal switch.

Sleeve gastrectomy, also known as gastric sleeve, is a surgical weight loss procedure in which a large portion of the stomach is cut-away and removed from the body. The remaining stomach is about 25% of its original size and resembles a narrow sleeve or tube with a banana shape. The procedure is usually performed laparoscopically and is not reversible.

For many years, sleeve gastrectomy was considered just the first stage of a two-part procedure. The operation would be followed up with gastric bypass or duodenal switch at a later time. This staged approach was considered safer for higher risk, severely obese patients. It has only been in recent years that sleeve gastrectomy has emerged as a stand-alone primary weight-loss procedure.

In order for Medicare beneficiaries to qualify for weight loss surgery coverage, they must have a BMI of 35 or greater, at least one weight-related problem (diabetes, heart disease or sleep apnea), documented evidence (in medical records) of repeated failure to lose weight in medically supervised weight loss programs (diet, exercise programs/counseling or drug therapy), and undergo a psychological evaluation.

If Medicare beneficiaries meet the qualifications, the cost of weight loss surgery will only be reimbursed if all other medical treatments have been ruled out, the surgery is performed at a Medicare-approved Center of Excellence, and the specific bariatric procedure used is approved by Medicare. The out-of-pocket expenses will depend on the type of Medicare plan under which the patient is covered.

The CMS will seek public comment until October 30th, 2011 regarding coverage of laparoscopic sleeve gastrectomy. The agency plans to review the evidence and issue a proposed decision by March 30, 2012, and to make a final decision by June 30, 2012.

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5 thoughts on “CMS Considers Coverage of Gastric Sleeve

  1. I am praying for Medicare to cover the gastric sleeve. I had to have emergency surgery to have my lapband removed due to a slip and total collapse. Five years post and 86 pound loss and now I am gaining weight without a tool to help. I did not have Medicare when I got the lap band and now Medicare is my primary and they do not cover the sleeve at the present time.

  2. Today is 4/3/12 and still no news as to whether or not CMS has accepted
    the gastric sleeve. We were supposed to hear by 3/31/12. Please give
    me some new information. thanks

  3. I only see that Medicare beneficiaries may be covered for the Sleeve Gastrectomy. But how about Medicaid beneficiaries? Does Medicaid cover the sleeve on a case by case basis?

  4. I would have this procedure if it would be available I believe it would be very beneficial to over all health.

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