A Strong, United Voice For Sleeve Gastrectomy
Leads to Nationwide Coverage
By John Morton, MD, MPH, FACS
It is now almost exactly two years since CMS re-opened the Bariatric Surgery National Care Determination for possible inclusion of the laparoscopic sleeve gastrectomy. You can see a timeline below of the events that took place over the past two years to lead us now to a point where there is now nationwide CMS coverage for sleeve gastrectomy (see related article). The entire experience has been highly educational, motivational and inspirational for me. First and foremost, I am so proud to be part of a society that is engaged, informed and puts the patient first. I also learned through this process that the following
MESSAGE - Safe & Effective
We all decided that the message regarding the sleeve gastrectomy was simple: it is safe and effective and lies right between gastric bypass and gastric band for those two outcomes. We repeated this message over and over until the message gained traction.
DATA - Value of Registry
CMS, like many payors, demand data to support views. ASMBS was, and remains fortunate, to have a clinically rich data registry that allows us to demonstrate our practices’ worth and utility. After showing CMS data from over 250,000 cases, I also presented the comparative data for bypass, band and sleeve at the ASMBS 2012 meeting. The supporting data drove discussion in our favor.
UNITY - 598 positive comments and 3 negative comments
It is almost proverb that more than two surgeons can’t agree on anything. However, when it came to sleeve gastrectomy, over 500 surgeons agreed and sent their comments to CMS supporting sleeve gastrectomy coverage in the two different comment periods. ASMBS utilized a rapid response call for comments and provided supporting bullet points and web links.
Having all the partners in the Obesity Care Continuum support this coverage decision was extremely heartening. All of our partners stepped up and publicly called for coverage. Behind the scenes, we have worked with them on many other advocacy projects building trust and relationships to all of our benefit. Our advocacy partners included American College of Surgeons, Society of Advanced Gastrointestinal Endoscopic Surgeons (SAGES), The Obesity Society, American Society of Bariatric Physicians, and the Obesity Action Coalition.
As you can see from the two-year timeframe, patience was a virtue as was optimism. It is very easy to be patient and optimistic when you know you are on the right side of the patient and science. We all knew our message was true and time proved the message correct and appropriate.
To go along with patience, we needed persistence. As you can tell from the below dates, we had to respond continuously, appropriately and vigilantly. CMS devolved the responsibility for coverage from the national office to the regional Medicare Administrative Contractors who we had to learn about and also engage on a local level employing the below local ASMBS representatives. We had to keep checking that the non-coverage designation for the sleeve was removed, the RVU restored and age restrictions removed.
CMS Coverage for laparoscopic sleeve gastrectomy is a noteworthy achievement for ASMBS that I am very proud to have led. This coverage decision exemplifies that we work best when we work together for all of our patients. This was truly a team effort that includes, but is not limited to the following ASMBS members and staff:
Bruce Wolfe, MD
Jaime Ponce, MD
Robin Blackstone, MD
Ninh Nguyen, MD
Matt Brengman, MD
Teresa LaMasters, MD
Christopher Joyce, MD
Lloyd Stegemann, MD
Wayne English, MD
Brad Needleman, MD
Joe Northup, MD
Brandon Williams, MD
Dan Jones, MD
Mitch Roslin, MD
Michael Schweitzer, MD
John Scott, MD
Keith Kim, MD
CMS SLEEVE TIMELINE
August 22, 2011
CMS received an informal request for reconsideration of the Bariatric Surgery for the Treatment of Morbid Obesity NCD to review evidence for inclusion of sleeve gastrectomy
September 30, 2011
CMS opens NCD reconsideration request to review the new evidence for laparoscopic sleeve gastrectomy.
March 29, 2012
Proposal to cover LSG as part of an RCT
June 29, 2012
Reconsideration of LSG proposal achieved
ASMBS Response Letter to CMS
October 1, 2012
Non-coverage of Sleeve Removed
November 12, 2012
ASMBS Letter to all Medicare Administrative Contractors re LCDs Prior institution of coverage for the LSG via local MAC Assist in crafting Local Care Determination.
February 7, 2013
ASMBS Letter to LCDs without coverage or Age Restriction or Preop Weight Loss Requirement
August 30, 2013
Public Comments Close for Removal of Final LCD with Age Restriction (Palmetto)