Sleeve Gastrectomy Update: CMS Coverage Spreads Through U.S.

Published in August 2013 Issue             

CMS now routinely covers laparoscopic sleeve gastrectomy nationwide after a dedicated, focused and unified ASMBS effort led by Dr. John Morton. Initial CMS reconsideration of the Bariatric Surgery for the Treatment of Morbid Obesity National Care Determination to review evidence for inclusion of sleeve gastrectomy began August 22, 2011. Two years later, coverage is now near complete, as shown in the coverage map of the United States.

Palmetto, one of two final Medicare Administrative Contractors (MAC) to have an age restriction for Laparoscopic Sleeve Gastrectomy, has a Proposed Draft for a Local Coverage Determination (LCD-DL32975), which will allow sleeve coverage for age > 61 if the following conditions are met. Nordian, the other MAC with an age restriction, will assume direction of the Palmatto region and will likely honor the Palmetto LCD.

1. Surgery must occur at a Medicare approved bariatric center by a board certified surgeon and/or a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Accredited Surgeon.

2. In addition to the nutritional and psychological evaluation previously outlined in this local coverage determination, there must be evidence documented in the patient's medical record that the patient is able to personally understand the nature and potential complications of surgery and has the capacity to follow the postoperative care and nutritional requirements, and the patient must sign the informed consent personally.

3. Indications for surgery in this age group will include at least one of the following serious comorbidities: Diabetes Mellitus, OR Hypertension not well controlled with a single medication, OR Hyperlipidemia requiring more than one medication to manage, OR Joint Disease requiring surgical Intervention or Gastroesophageal Reflux Disease (GERD) refractory to a two month trial of appropriate treatment and medications, OR Obstructive Sleep Apnea requiring CPAP, OR Potential organ transplant candidacy at a UNOS-certified center whereby a BMI ≥ 35 is required.

4. Contraindications include: Dementia to the extent that self-care is precluded (including exercise and nutritional care), Requirement for Home Oxygen therapy and Organ failure unless patient is a transplant candidate to replace the failing organ at an UNOS-
certified center.

The public comment period will close August 30, 2013, and it is anticipated that a revised Local Care Determination will be in effect by October 1, 2013.

For more details regarding the Palmetto LCD or to submit a comment in support of the removal of the age restriction, please click here.