Access to Care Update – December 2012

Access To Care Update

ASMBS recently sent a letter on the Local Care Determinations by regional Medicare Administrator Contractors to all the regions. In the letter, Access to Care Chair John Morton, MD argued for uniform coverage for all CMS patients regardless of age or previous weight loss attempts. All regions will be reviewing local comments. Final determinations will most likely be made in Feb 2012. Until written clarification is provided, ASMBS advises to have patients sign potential non-coverage agreements prior to surgery or waiting until final written determination. Download PDF of letter here.

Also, Blue Cross TEC has deemed gastric bypass to have benefit for patients with BMI 30-35. This exciting development may lead to more access for patients. View full update here.

John Morton, MD, MPH, FACS, FASMBS
Secretary-Treasurer, ASMBS
Access to Care, Chair


Local Update on Laparoscopic Sleeve Gastrectomy Coverage for Medicare Patients

  • Wisconsin Physician Services (WPS) is the regional Medicare Administrative Contractor providing Part A & B coverage for the states of Michigan, Indiana, Iowa, Kansas, Missouri and Nebraska, and Part B coverage for the states of Wisconsin and Illinois.
  • WPS announced that it has reversed its decision to limit sleeve gastrectomy coverage to Medicare patients under the age of 61 if patients meet specific criteria.  They cited that new literature received during the public comment period (which ended November 26, 2012) for the draft Local Coverage Determination (LCD) has led them to remove the age limit and that the finalized version of the LCD will reflect this change.  A recent WPS e-newsletter indicated that sleeve gastrectomy coverage is effective as of December 1, 2012.

The current status of sleeve gastrectomy coverage for Medicare patients throughout the United States remains in flux and many states are still in the process of finalizing their decisions.  As of today:

  • 21 states have unrestricted coverage for sleeve gastrectomy in Medicare patients
  • 7 states have coverage for age 64 years and younger only; age 65 and older is excluded
  • 11 states have coverage for ages 60 and younger only; age 61 and older is excluded
  • 11 states and Washington DC currently have no coverage
Wayne English, MD, FACS
Access to Care, Co-Chair

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