Drs. Wayne English (Access to Care Chair), Lloyd Stegemann (TX Chapter President), and John Morton (Secretary-Treasurer) are pleased to announce that Novitas Solutions (JH) jurisdiction has posted a revised medical coverage policy now covering Laparoscopic Sleeve Gastrectomy (LSG), effective December 21, 2012, for Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas. Also note, for Sleeve claims with dates of service on or after June 27, 2012, Novitas Solutions will cover all claims that are currently in their system for both Part A (hospital services) and Part B (physician services). Attached is a copy of the revised coverage policy for your review. Further updates will be forthcoming for the rest of the nation.
Below is a brief overview Novitas Solutions LSG medical policy:
Contractor Local Coverage Policy
Bariatric surgery procedures must be performed by a surgeon trained and substantially experienced with surgery of the digestive tract, working in a clinical setting with adequate support for all aspects of management, assessment and follow-up. The American College of Surgeons (ACS) and American Society for Bariatric Surgery (ASBS) certification requirements for physician and institutional credentialing satisfy this requirement. Physicians and institutions who do not meet ACS or ASBS certification criteria for performing bariatric procedures do not qualify for Medicare payment for these procedures.
Laparoscopic Sleeve Gastrectomy for morbid obesity is covered under Local Coverage Determination by this contractor to include patients with the three above criteria (BMI 35 or greater, at least one comorbidity related to obesity and previous unsuccessful medical treatment for obesity) as the following:
- Laparoscopic Sleeve Gastrectomy only performed in a designated Medicare Center of Excellence for Bariatric Surgery
- Laparoscopic Sleeve Gastrectomy for a ‘stand-alone’ procedure (i.e., not as part of staged procedure or part of failed attempt that moves to an open procedure)
Note: For additional coverage and coding guidelines please download the full PDF.
Here is a brief status report on the current landscape of sleeve gastrectomy coverage throughout the country:
- 26 states have sleeve gastrectomy coverage for all Medicare patients
- 7 states have limited sleeve gastrectomy coverage for age 64 years and younger; age 65 and older is excluded
- 11 states have limited sleeve gastrectomy coverage for ages 60 and younger; age 61 and older is excluded
- 6 states and Washington DC currently have no sleeve gastrectomy coverage