In 2006, CMS expanded coverage of bariatric surgery for Medicare beneficiaries who receive one of four procedures gastric bypass, open and laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and open and laparoscopic biliopancreatic diversion with duodenal switch in bariatric centers of excellence, as certified by the American College of Surgeons or the American Society for Bariatric Surgery, and as reported on the Medicare coverage Web site. To be considered for coverage, Medicare beneficiaries must have a BMI of 35 or higher and must have exhibited a serious health condition in addition to morbid obesity, such as hypertension, coronary artery disease, or osteoarthritis. Type 2 Diabetes would join the list of serious health conditions.
However, after “a careful review of the medical evidence available on bariatric surgery,” CMS is also proposing to not cover bariatric surgery for patients who do not meet the definition of morbid obesity, even if they do have type 2 diabetes.
“While recent medical reports claimed that bariatric surgery may be helpful for these patients, CMS did not find convincing medical evidence that bariatric surgery improved health outcomes for non-morbidly obese individuals,” says the agency.
CMS is seeking comments from the public about this evidence and its implications for coverage, and about which groups of patients should be covered for this surgery. Public comments may be submitted directly to CMS’s Coverage Web site for 30 days from the Nov. 17 posting of the proposed decision memorandum. CMS will issue a final decision memorandum within 90 days of the proposed decision.
Read the proposed decision memorandum and submit comments at the CMS Coverage Web site.
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