On June 27, 2012, The Centers for Medicare and Medicaid Services (CMS) released their decision on coverage for the laparoscopic sleeve gastrectomy (LSG). The final decision will allow laparoscopic sleeve gastrectomy to be covered by intermediary Medicare administrators as a stand-alone procedure at their discretion. The text of the decision is below.
On behalf of our patients, ASMBS is very pleased and gratified that CMS has recognized the true value and compelling need for coverage of this procedure. ASMBS will immediately initiate the formal pathway for coverage with each regional CMS intermediary by reiterating the arguments for coverage as expressed in our excellent April 2012 appeal letter written by John Morton, MD (Access to Care Committee Chair and Secretary/Treasurer) and Matt Brengman, MD (Insurance Committee Chair) ASMBS Response to CMS Sleeve Coverage Decision.
In addition, in the Top 5 on the 5th July 2012 newsletter from ASMBS, the Access Committee will provide additional instructions as to how you and your patients can help in the effort to achieve coverage in each particular region of the country. This again demonstrates our future need to work together in regional collaboration.
While more work needs to be done, this experience demonstrates that the ASMBS Rapid Response Initiative for Access to Care works. The overwhelming response from patients, surgeons and integrated health members, along with the strong evidence base for LSG, provided CMS with a persuasive argument for LSG coverage. In addition, the multi-disciplinary support of the American College of Surgeons, SAGES, The Obesity Society and the American Society of Bariatric Physicians displayed an Obesity Care Coalition in action working for our patients’ best welfare. We are thankful to the Obesity Action Coalition and our industry partners, Covidien and Ethicon, who all played vital roles. We will now go forth to each individual intermediary, and this decision will open the door to widespread coverage based on the strong, available evidence. We are confident coverage will be achieved.
STAY TUNED FOR ADDITIONAL PLANS in the Top 5 on the 5th newsletter TO UNDERSTAND YOUR ROLE in obtaining coverage in your area.
Jaime Ponce, MD
Robin Blackstone, MD
Immediate Past President, ASMBS
Ninh Nguyen, MD
John Morton, MD
Secretary-Treasurer & Chair, Access to Care Committee ASMBS
Matthew Brengman, MD
Chair, Insurance Committee ASMBS
Medicare Administrative Contractors acting within their respective jurisdictions may determine coverage of stand-alone laparoscopic sleeve gastrectomy (LSG) for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries only when all of the following conditions A-C are satisfied.
- The beneficiary has a body-mass index (BMI) ≥ 35 kg/m2,
- The beneficiary has at least one co-morbidity related to obesity, and
- The beneficiary has been previously unsuccessful with medical treatment for obesity.
CMS Conclusions & Rationale for Decision:
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. 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. Our local contractors are in a better position to consider characteristics of individual beneficiaries and the performance of eligible bariatric centers within their jurisdictions. Therefore, Medicare Administrative Contractors acting within their respective jurisdictions will make an initial determination of coverage under section 1862(a)(1)(A) and we are not making a national coverage determination under section 1869(F).
LINK TO COMPLETE CMS DECISION MEMORANDUM: http://go.cms.gov/KOKy4g