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Weight loss surgery: Medicare backs off nationwide coverage decision

Wed, 06/27/2012 - 6:06pm
Mass Device

The Centers for Medicare & Medicaid back off of making a nationwide Medicare coverage decision for laparoscopic sleeve gastrectomy in treatment for morbid obesity, deferring instead to local decision-makers.

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The Centers for Medicare & Medicaid Services backed off making a nationwide decision on whether laparoscopic sleeve gastrectomy is "reasonable and necessary" in treatment of morbid obesity, thus leaving the question open as to whether the procedure is reimbursable by Medicare.

Instead of deciding one way or the other, CMS deferred back to local Medicare contractors to determine on a case-by-case basis which patients would benefit most from the procedure.

"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 LSG," according to the CMS decision. "However, taking into consideration the seriousness of obesity, the possibility of benefit in highly selected patients in qualified centers, we believe that local Medicare contractor determination on a case-by-case basis balances these considerations in the interests of our beneficiaries."

CMS reported that it will not make any national coverage decisions regarding LSG, but that the procedure remains an option for patients who satisfy certain conditions:

  1. The patient must have a body mass index of at least 35 kg/m2
  2. The patients must have at least one co-morbidity, which may include Type II diabetes
  3. The patient must have tried and failed medical treatment for obesity

"Consideration of long term benefits and harms must be carefully weighed to ensure that there is a clinically meaningful benefit, as bariatric surgery does historically have significant associated morbidity risks and even mortality," the agency added. "While LSG may be promising for some individuals with obesity, the underlying disease conditions leading to their Medicare eligibility may speak to pertinent clinical factors that would make LSG more or less appropriate management."

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