On June 27, 2012, the Centers for Medicare & Medicaid Services (CMS) issued a final decision memorandum allowing coverage of laparoscopic sleeve gastrectomy on a case-by-case basis for Medicare beneficiaries.
The CMS opted not to make a national coverage determination and instead let regional medicare administrative contractors, who “are in a better position to consider characteristics of individual beneficiaries and the performance of eligible bariatric centers within their jurisdictions,” to make an initial determination of coverage.
This position represents a turnaround from the proposed decision memorandum published earlier this year that would have only allowed coverage of LSG within a randomised controlled trial. Since that time, the CMS took into account the availability of new data as well as additional input from the surgical and patient community.
The decision summary states:
Medicare Administrative Contractors acting within their respective jurisdictions may determine coverage of stand-alone laparoscopic sleeve gastrectomy (LSG) for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries only when all of the following conditions A-C are satisfied:
A. The beneficiary has a body-mass index (BMI) = 35 kg/m2,
B. The beneficiary has at least one co-morbidity related to obesity, and
C. The beneficiary has been previously unsuccessful with medical treatment for obesity.
In their conclusion, CMS said that “taking into consideration the seriousness of obesity, the possibility of benefit in highly selected patients in qualified centers, we believe that local Medicare contractor determination on a case-by-case basis balances these considerations in the interests of our beneficiaries.”
The decision memo states that the laparoscopic sleeve gastrectomy procedure will be covered only when conducted as a stand-alone definitive treatment and not when performed as part one of a two stage surgery (second stage involves a malabsorptive component, such as duodenal switch). Also, open sleeve gastrectomy is not covered.
The Bariatric Surgery for Treatment of Morbid Obesity National Coverage Determination (NCD) further stipulates that bariatric surgery is covered only when performed at facilities that are either certified by the American College of Surgeons (ACS) as a Level 1 Bariatric Surgery Center or certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (BSCOE).
Source: CMS Decision Memo for Bariatric Surgery for the Treatment of Morbid Obesity (CAG-00250R2)
Related Articles: CMS Considers Coverage of Gastric Sleeve and CMS Issues Proposed Decision for Sleeve Gastrectomy