Medicare May Cover Gastric Sleeve Surgery

The Centers for Medicare & Medicade Services (CMS) has released its decision concerning insurance approval of the laparoscopic sleeve gastrectomy (LSG) procedure for clinically obese patients. Although the agency will not issue a National Coverage Determination, the CMS decision memo states that is up to the discretion of local Medicare contractors to determine whether they will pay for laparoscopic sleeve gastrectomy, or gastric sleeve as it is more commonly known, to treat extremely obese patients.

Medicare May Cover Gastric Sleeve SurgeryFor a Medicare beneficiary to be eligible for coverage of the sleeve procedure, three conditions must be met:

  • The patient must have a body-mass index (BMI) of over 35.
  • The patient must have at least one other condition that is related to obesity.
  • The patient must have been unsuccessful with previous medical treatments for their obesity.

CMS had previously approved coverage for three other bariatric procedures: Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and biliopancreatic diversion with duodenal switch. However, a staff agency review had found that sleeve gastrectomy had not been efficiently studied in patients over the age of 60 and questions still remained as to whether or not the benefits outweighed the risks involved for the Medicare population.

“The available evidence does not clearly and broadly distinguish the patients who will experience an improved outcome from those who will derive harm such as postoperative complications or adverse effects from laparoscopic sleeve gastrectomy,” the CMS said in a final decision memo released on June 27th.

Nonetheless, the CMS decided in the end to let regional contractors pay for the procedure on a case-by-case basis, because of “the seriousness of obesity [and] the possibility of benefit in highly selected patients in qualified centers.”

States the memo, “Our local contractors are in a better position to consider characteristics of individual beneficiaries and the performance of eligible bariatric centers within their jurisdictions.”

One Response

  1. Wanda Winters

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