CMS Considers Medicare Coverage for Gastric Sleeve

Gastric sleeve surgery soon may be covered by Medicare, following a review of public comments demonstrating evidence of the procedure’s effectiveness for the treatment of obesity.

The Centers for Medicare and Medicaid Services (CMS) soon will begin its review of public comments on a proposal to cover gastric sleeve surgery for Medicare patients suffering from morbid obesity.

CMS Considers Medicare Coverage for Gastric SleeveCMS received an informal request on August 22, 2011, for consideration of sleeve gastrectomy as a covered procedure. Today is the last day of the one-month period during which CMS solicited comments as to “whether there is adequate evidence, including clinical trials, for evaluating health outcomes of laparoscopic sleeve gastrectomy (LSG) for the indications listed in the current Bariatric Surgery for the Treatment of Morbid Obesity National Coverage Determination.”

Gastric sleeve surgery involves removing approximately 75-80 percent of the stomach to restrict the amount of food that a patient can comfortably eat, thereby limiting caloric intake and promoting weight loss. Unlike with gastric bypass surgery, gastric sleeve surgery does not involve rerouting or bypassing any portion of the small intestine. Rather, the remaining stomach pouch, which is shaped like a tube or sleeve, remains connected to the natural stomach outlet (pyloric valve). As a result, gastric sleeve patients have a lower risk of malnutrition and dumping syndrome.

Research indicates that morbidity and effectiveness rates for gastric sleeve surgery fall between those of Lap-Band and laparoscopic Roux-en-Y bypass procedures; however, long-term studies are limited.

Currently, Medicare covers open and laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding (commonly known as the Lap-Band procedure), and open and laparoscopic biliopancreatic diversion with duodenal switch. Patients must have a body mass index (BMI) of 35 or higher and have at least one obesity-related comorbidity, such as type 2 diabetes or heart disease. Other physician-supervised treatments for the management of obesity must be shown to have been ineffectual, and the procedure must be performed at a surgical facility that meets specific standards specified by CMS.

The agency plans to issue a proposed decision on coverage of laparoscopic sleeve gastrectomy by March 30, 2012, and to make a final decision by June 30.

UPDATE (June 30, 2012) The Centers for Medicare and Medicaid Services released its ruling this week regarding Medicare coverage for gastric sleeve surgery. Click here for details.

38 Responses

  1. DIANA BAIZE

    Well, I am really caught between all of this. I had Lap-Band surgery in 3/06 (deleted my retirement funds!!). From this I have only lost 30 pounds. For the last 2 years I have suffered from over-fill in my lap-band which involved nausiation, vomiting, malnutrition (hair loss, brittle nails breaking, etc.) but still no weight loss!! I have had everything checked like thyroid, my gastronologist ran some tests just to make sure it is not me. Everything is fine so I had to have my band unfilled to start over again. They & I both feel that this surgery is not going to to work for me. The reason I did this surgery was to prolong my life. I suffer from diabetes type 1 (38+ yrs); Severe Sleep Apnea; C.O.P.D.; high blood pressure (take apprx. 5 pills for this); arthritis in hips, knees, hand knuckles, lower back problems (Degenerative Disk Disease), etc. I have to take apprx. 10-12 pills daily some of them 2 x day. I was hoping with the Lap-Band surgery I would already be off of some of these pills, & lost maybe most of my weight (I needed to lose over 100 lbs.). I have not been able to do any of this. Now I hear if you guys cover these surgeries you have to at least be 100 lbs. overweight!?! I only had to be 50 lbs. overweight back in 2006 in order to have the lap-band done. For someone with all of my medical history 100 lbs. is way too much extra weight to have on me. Was sondering if you are going to lower your rules of only being 100 lbs. overweight to get this done?? I have way too much medically wrong with me to be 100.5 lbs wrong with me & possibly not be able to get this surgery I desperately need to have done. Can you email me with some good news maybe when a decision has been made on whether or not you are going to consider the Gastric Cleeve? My nurses say this is the surgery that will be much safer take over the Gastric By-pass surgeries in the future. Does not sound as harmful of dangerous to me which is why I went with the Lap-Band to begin with. Thanks.
    Diana Baize

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  2. Anthony Julian

    Does anyone know when CMS is supposed to make this decision public??

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  3. Vicki M.

    Is there any update to Medicare approving the gastric sleeve? Since I don’t have personal insurance other than Medicare, I am eagerly awaiting their news. I’m praying they will soon include it on the approved list or I think I will die from this weight. Thanks. Vicki

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  4. Johnie Morris

    I had the operation done January 16th. My Kaiser Insurance covers a large portion of it but Mdeicare covers nothing, leaving me with thirteen grand out of pocket. Typical government beauracracy, they cover a more invasive and more expensive surgery but not a less invasive and less expensive one.
    With or without Medicare, it’s worth it because it’s saving my life. I haven’t been hungry since the surgery, I actually forget to eat and my wife has to remind me. I lost 27 pounds on the 13 day liver shrinking diet and an additional 13 pounds in the 12 days following surgery. Over the past 7 days I have averaged 2.3 pounds weight loss per day. Since entering the classes before surgery and the liver shrinking diet, I have gone from 391 pounds down to 341, a loss of 50 pounds. I’ll be satisfied when I have lost 191 pounds.

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  5. S Motega

    I am very excited that this sleeve may be covered. I will be one of the first patients running to the Surgeon’s office for consideration. This surgery has worked for so many people without all the complications of the other surgeries. I almost got the lapband but had to be dismissed from the hospital on my scheduled surgery day after being prepped for surgery because of an unexplained fever. I am very happy I didnt have it done now because of the very poor results seen in lapband patients. If this surgery gets approved, it will save SO many lives. I hope mine is one of them.

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  6. Ms. Janice

    I am a 55 yr old african-american female. I have been a type 2 diabetic for the past 21 years. I suffer from other conditions such as arthritis (degenerative and osteo); coronary artery disease, chronic kidney disease (stage 3); degenerative disc disease (have had 2 back surgeries), etc. I am currently scheduled for bariatric surgery (lap band) on April 9, 2012. Several of my friends have had the gastric sleeve and I had 2 persons I knew personally to pass away within the last 2 months from complications from the gastric bypass surgery. They developed infections that went throughout their bodies and killed them.

    My doctor originally recommended the sleeve surgery, but when I disclosed that I was on social security disability and had medicare, I was then told medicare would not cover the sleeve at this time.

    I am hoping that on March 30th when information is released with a proposed decision of coverage on this procedure of the gastric sleeve, that I may be able to delay my surgery until I can obtain approval in the not so distant furture, see that I have and do meet all of the requirements.

    This surgery is also a last resort for me because of coronary artery disease, which has shown that I currently have 4 areas of blockages at 50-70% block. I was told that I needed the surgery to now, otherwise if there is another episode with my heart, the door to the bariatric surgery could close. I am praying that medicare will pass this soon.

    It is ironic that tonight on the world news NBC, one of the main topics was about their being a possible cure of type II diabetics with bariatric surgeries, mainly the gastric bypass and the sleeve. It was stated that almost immediately after those procedures, without any weightloss, that the patients blood sugars are reading normal within hours of the operation. Good news!!!

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  7. patsy

    will you pleae e-mail me when the decision comes down and hopefully apprval for the sleeve. I have been told that this is the one for me and that i need this one and meet the qualifications for it. I know several people who have had this one and have lost 100 pounds each with no problems. I need to loose 100 pounds to prolong my life.

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  8. Louann

    Can you let me know when Medicare will cover gastric sleeve. Please

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  9. Di

    The article says that they will make their decision by June 30, 2012. So, they will probably make it public by a week or two later since it is so monumental………..and it is an election year! Any way, I’m very glad to hear that they are considering it because it’s the one the doctors want me to have. I need to lose almost 200 pounds. If you all believe in prayer, please pray for me and every one else who can even remotely benefit from this that it is approved. OK? Also, I have type II diabetes, high blood pressure, cholesterol, strokes, and more that will benefit from weight loss…..

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  10. Sharra

    Medicare. Money will be saved if you OK the sleeve. Unfortunately, I think that is all you care about. So, I hope you decision makers can see that allowing the sleeve is a good idea, because it is safer, therefore cheaper in the long run, than the bypass during and after surgery, and has almost the same medical benefits as the bypass, and many more medical benefits than the lap band which you already approved.

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  11. Kymmi

    Im waiting on this day because I’m trying to get this surgery done and need my insurance which is Medicare to cover this:)

    Reply
  12. Marlene

    I would like to know when Medicare makes a descision about the gastric sleeve I had colon cancer and had to have 12″ of my colon removed I hae been told the sleeve is the only safe surgey I can have. I have at least 100 pounds to lose I am 55 years old I feel like this is the surgery that can improve my life

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  13. Sunny

    I await this decision with excitement. If Medicare approves for men to get very expensive penis implants, why not the gastric sleeve? I work two jobs and struggle with my health daily. I sure would benifit from this proccdure and not feel like I was risking my life to have it. In skilled hands it is safer than the other weight loss surgeries with less danger of problems as life goes on. As a constant dieter with yoyo results I feel like this proceedure would be the answer to years of frustration for me.

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  14. Nancy Donovan

    I also need the sleeve very badly…I have a huge surgery I have to have and cannot have it unless all my weight has gone…so I am urgently waiting the sleeve….WHEN IS THIS GOING TO HAPPEN….??????

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  15. Linda

    To the powers that be…MEDICARE..PLEASE APPROVE THE GASTRIC SLEEVE SURGERY. I need to lose 120 pounds and want desperately to get rid of type II diabetes and high blood pressure and other problems. I need a hip replacement operation and was told they won’t touch me unless I lose the extra weight first. My grandmother went blind and lost a leg and then died from complications of type II
    diabetes..I do not want to continue this pattern. Please realize from a monetary point of view how much money medicare would be saving if they are curing type II diabetes..a disease which affects the kidneys and at that point cost $75,000 a year for dialysis treatments not to mention the intense suffering..unneccessary suffering..that people have to endure. This decision involves common sense and human compassion. Any operation that could potentially cure type II diabetes should be approved immediately if not sooner…..because diabetes can progress to such horrible consequences. I will resort to prayer if I have to…Please APPROVE THE GASTRIC SLEEVE OPERATION ON JUNE 30TH. Life is hard enough…A life without diseases and obesity can only mean a longer and healthier life…Please approve this surgery!!!!!!!!!!!!!!

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  16. Erika Robinson

    I am hoping that the VSG gets approved, I am so happy and can’t wait, I was considering the Lap Band, but read and seen others comments about the Gastric sleeve that I know I am ready to get the sleeve done, my BMI is states that I am severely obsessed and this procedure will fit me like a glove, I can’t wait!!!

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  17. Mike

    The sleeve seems to be the least invasive and simplest…I came close to getting a lap band but the foreign object idea turned me off….I am type 2 diabetic with 15 years of injections and meds….I am on Medicare so I might be forced to do the whole bypass if this one is not approved…I weigh 280 lbs (down from 320 with two years of regular excercise and modified diet) My biggest fears involve eyesight and feet/legs, having three uncles who lost legs to diabetes…retired, with a fair income..the $18,000 is still a possibility but there should be a way medicare can cover SOME of the cost. I have very good supplemental….but money is too tight at the moment…will there be a way to become part of an experimental group if it is not passed? I know others need it more than me…but I want to live without diabetes for the rest of my life….fingers crossed….I guess the decision is June 30th but I don’t hold out much hope based on the recommendations I have seen on log term evidence and data…..good luck all of you…make that all of US

    Reply
  18. KATE

    I was all for the lap-band because it was least invasive. Later, I heard I can’t take nsaids with it. I have sever arthritis pain, can barely walk even with all the pain meds and nsaids. I’d be a cripple without the meds. That’s why I’m such a sleeve advocate … and of course it’s safer.

    I’ve tried to find out more about the new decision, but nada. So we’ll have to wait till June 30. Please post here as soon as you hear. Thanks.

    Reply
  19. Linda

    Hi there…it’s Linda again. Just another point to consider…TIME IS OF THE ESSENCE! The sooner surgical intervention takes place the better the chances of
    getting rid of the horror of living with type II diabetes…that is what all the surgeon’s say…there is no time to waste. This surgery is being done every day of the week in hospitals and other places all over the United States. The evidence is all over the place if CMS will take the time to investigate this. Just think..the more people that have it done…the more results to document. You
    can always stop the coverage if studies show it is ineffective…but all types of
    statistics beg to differ. People are losing tons of weight and improving diabetic outcomes…if not getting rid of it altogether…The approval of this surgery is an URGENT matter…would begging help? OK … I’m begging….PLEASE APPROVE THIS SURGERY..You’ve already approved several that made an interesting beginning in this war on obesity and the medical suffering that goes along with it..well please approve the safer, cheaper, and best to live with…Please prove that the United States of America has not lost it’s interest in caring about the lives and health of it’s citizens…Eagerly awaiting the approval of this terribly needed procedure…Am even willing to say thank you in advance. Thank you!

    Reply
  20. annoymous

    Final decision is June 30 2012 four more days. I got sick of waiting went to mexico now medicare has to $250,000 for all the problems, I came back with, but no leaks, blood clots and infections. So americans are assholes.

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  21. annoymous

    I had blood clots and infections so you know, had to be in the hospital twice for days and er 5 times. Don’t go to Mexico my surgery was only $4,499 and they talked about this doctor like he was god, but messed me up.

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  22. Marlene

    I had a lap band on April 18, 2012. Never had it filled…went for first fill and had a port infection starting, so I had to have the lap band removed. This was on June 13th.

    I was told that since I lost down to a BMI of 34.8..now I have to GAIN weight to have approval from Medicare to place another band or have a bypass…GAIN weight…please

    Is there not a way to have medicare use the old BMI number and grant me another chance to have a tool for weight loss. BMI 34.8 is not good…

    Also want the sleeve and was my first choice….but as of yet..Medicare has not approved this procedure…not saying that if I had the sleeve first I would not have trouble with the sleeve, but the band placement caused the infection in the first place

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  23. Suzie Craig

    I have one question for all of you that are morbidly obese and seem to think it is somehow owed to you to have this surgery and people like myself and my husband and children have to work to contribute to the same medicare that will pay for your surgery. My question: how many of you eat all day long and in huge quantities? You do nothing at all to help yourself lose weight. And you wonder why people like me are disgusted with overweight [people] such as yourself. I find it offensive that I have to work my tail off so you can use the funds that I contribute to. Don’t tell me you work because if you did you wouldn’t be on medicare. You choose to overeat and become obese….you should suffer the consequences.
    [NOTE: This comment was edited by the administrator]

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  24. Rhonda

    Suzie:
    I too am a tax paying individual and my husband became ill in 2002 and went on disability, only after he worked for 27 years and paid into the Medicare plan that he now receives. It is very presumptive of you to determine that people who are on Medicare have not contributed to the plan. In fact most people on Medicare have worked and paid for many years. Are you confusing Medicare with Medicaid?

    Because you are so concerned with how your dollars are being spend you should be the first to want these people to have the surgery. I had the surgery in 2010 (don’t worry I paid for it myself) and have lost 200 pounds and my medical expenses are nonexistent compared to back then. So in essence they are saving you money by having the surgery.

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  25. Dana W

    First of all, the surgery is not approved at the local levels yet. It is only agreed upon by Medicare per their national guidelines. Much has to be done and can take a while for the local contracted intermediaries (here in Florida it is called “East Coast Service Options”) to create/approve/implement the LCD (Local Coverage Determination) for this procedure.

    I have been following this closely and hope that does not take too much longer!!

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  26. annoymous

    Suzie you are selfish, some people gain after children and medicare is for seniors that are 62 and over why should someone stay diabetic for you. i paid for my surgery and had to go to mexico and came back with a lot of problems. you know not what you do. words of christ.

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  27. Gail

    Suzie, you have a misunderstanding of medicare. I am retired and receive medicare I worked from the time I was 16yrs old until I was 62. Now You really believe that medicare was given to me. Sorry think again. Now for the overweight people that you have lumped together. You may have a problem with people that are overweight. That is your problem. How would you like to be looked at and stared at because of the way you look? I have been overweight all my life. In the 6th grade I weighed 160 lbs. I have tried almost every thing to lose weight. I have been check my many Drs. and I have been on diets from 1,200 calories a day to 500. On the 500 calorie I lost 80lbs in 3 months. On weight watchers I lost 2lbs in 6 weeks. I do not sit around and do nothing, swimming and exercise is something I do every day. You sitting in judgment of people is only hurting yourself. By the way I messed my blood up and it took about a year to get me healthy again. I am now 65 and still over weight I watch what I eat and I move it still will not come off so I can be (normal sized ?) I can only imagine what you think about some one that is 300lbs. Do not so quick to judge people you may be one of us someday. May God bless you and help you.

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  28. KATE

    Approval at the local levels … that is the key AND a cop-out. All Medicare did was push the problem/decision off their desks.

    I worked since I was 10, paid into Medicare for 50 years from age 16 to present (66). If I calculated it, I probably spent enough for my surgery but also surgery that dear Suzie may have to have when she gets Medicare. I feel sorry for people like Suzie because being narrow-minded and hating has got to be an awful way to live.

    Anyway, in Texas the local level is doing nothing. The company that has the contract has lost the renewal, which is in Oct. or Nov. That means no sleeve for me until further notice. I never wanted RNY but may have to go that route because I just can’t wait any longer. I’m 66, weigh 400 lbs., severe arthritis, bedridden. BTW I gained all my weight in the last 10 years from steroids I took during chemo for ovarian cancer.

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  29. farspike

    suzie, are your parents on medicare? Has it helped them in there retirement?you think this some is kind of an entitlement? Most honest people work all there lives and contribute to medicare look at your paycheck deductions.this was designed to help seniors im the golden years of life no matter what the situation. And in your final years hopefully it will be there to help you.Live long and prosper

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  30. Irma Middleton

    My husband is 43. On disability and has no quality of life. The sleeve was presented as a way to save his life. I have worked since I was 15 with parents approval on CO-0p, with no lapse in job. Sometimes working two. He is on medicare/medicaid. This surgery can save his life to help make it possible for him to get back to work. We have an 11 year old daughter I object to you thinking that 25 years of paying in and we are not use this health care. Pre-existing conditions still make it impossible to get insurance. We pay a premium each month for this, still. Are the people on unemployment also intitled (Susie). Currently, it is up to the individual insurance carrier to say yes or no. Molina Medicare is saying no.

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  31. Toni

    To Suzie – – Who probably hasn’t bothered to come back to this site to read her recriminations – – but here goes, anyway! Not only have most if not all of us worked and paid into Medicare for a half a century or more, we’re STILL paying for it! Our monthly premiums are automatically taken out of our Social Security payments! Personally, $99.90 comes out of my check each and every month to pay for Medicare coverage, and it will most likely go up in 2013!

    Reply

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