The CMS Laparoscopic Sleeve Gastrectomy National Care Determination was completed on June 27, 2012. Please review the below Frequently Asked Questions, keeping in mind that the decision allows for local Medicare administrators to approve coverage. Until clarity regarding local CMS coverage is achieved, performance of a LSG in a Medicare patient has potential for no reimbursement for surgeon and hospital alike. It is prudent to seek out local regional Medicare administrators regarding their policy prior to surgery and if you are denied after surgery, always request a peer-to-peer review. Also, you should approach your facility to review your own institutional approach to LSG coverage.
What is the CMS Decision?
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. Final text below.
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, and 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).
How Did the CMS Decision Happen?
Sept 2011 CMS opens this national coverage determination reconsideration request to review the new evidence for laparoscopic sleeve gastrectomy. CMS is requesting public comment on whether there is adequate evidence, including clinical trials, for evaluating health outcomes of laparoscopic sleeve gastrectomy for the indications listed in the current Bariatric Surgery for the Treatment of Morbid Obesity National Coverage Determination. After considering the public comments and reviewing relevant evidence, we will release a proposed decision memorandum. Instructions for submitting public comments can be found at http://www.cms.hhs.gov/InfoExchange/02_publiccomments.asp#TopOfPage
March 2012 Posted proposed decision memo
June 2012 Posted final decision memo.
What are Medicare Regional Administrators?
Medicare Administrative Contractors (MACs) are new entities created by CMS to integrate the administration of Medicare Parts A and B from the former fiscal intermediaries and carriers. The listing of the MACs is below.
Can I Start Performing Sleeve Gastrectomy in Medicare Patients?
Further clarification is needed from your regional Medicare Administrator. This may take months. The Access to Care Committee will coordinate with your regional champion State Access to Care Representatives (STARs) to ensure you can perform sleeve gastrectomy and be reimbursed. Prior to an official decision, centers have a risk of not being reimbursed when performing sleeve gastrectomy. There is always an option to appeal (see below).
Who is my STAR?
- MAC Jurisdiction E: California, Hawaii, Nevada: John Morton, MD
- MAC Jurisdiction F: Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming: Robin Blackstone, MD
- MAC Jurisdiction G: Iowa, Kansas, Missouri, Nebraska: Teresa LaMasters, MD
- MAC Jurisdiction G: Illinois, Minnesota, and Wisconsin: Christopher Joyce, MD
- MAC Jurisdiction H : Colorado, New Mexico, Oklahoma, Texas, Louisiana, Arkansas, Mississippi : Lloyd Stegemann, MD
- MAC Jurisdiction I: Indiana and Michigan: Wayne English, MD
- MAC Jurisdiction I: Kentucky and Ohio, Brad Needleman, MD & Joe Northup, MD
- MAC Jurisdiction J: Alabama, Georgia, and Tennessee: Brandon Williams, MD
- MAC Jurisdiction K: Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont: Dan Jones, MD
- MAC Jurisdiction K: Connecticut and New York: Mitch Roslin, MD
- MAC Jurisdiction L: Delaware, District of Columbia, Maryland, New Jersey, and Pennsylvania: Michael Schweitzer, MD
- MAC Jurisdiction M: North Carolina, South Carolina, Virginia, and West Virginia: John Scott, MD
- MAC Jurisdiction N: Florida: Keith Kim, MD
If Denied, How do I Appeal?
Contact your local Medicare administrator and use the below letters to formulate your written response. Always ask for a peer-to-peer review, you have the facts on your side and can be persuasive. Always get your patients involved.
Which Patients Should Receive Sleeve Gastrectomies?
The individual decision regarding which surgery for which patient is best left to surgeon and patient alike. Please consult the this link for further information.
Also, CMS has determined slightly different criteria for Medicare coverage as you can see below, mainly that any bariatric surgery patient have a comorbidity including BMIs>40. There is no current approved list of comorbidities. You may have to do a peer-to-peer review regarding comorbidity adequacy. In general, more comorbidities equal better chance for coverage particularly diabetes, hypertension, hyperlipidemia or sleep apnea. Also, CMS sleeve gastrectomy must be performed at CMS accredited centers.
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.
A. The beneficiary has a body-mass index (BMI) ≥ 35 kg/m2,
B. The beneficiary has at least one co-morbidity related to obesity, and
C.The beneficiary has been previously unsuccessful with medical treatment for obesity.
Medicare Regional Administrators:
- Palmetto (7) – MAC Jurisdiction E: California, Hawaii, Nevada
Feliciano, Harry, M.D., M.P.H
Palmetto GBA P.O. Box 1437
Augusta, GA 30903-1437
Work Phone: (803) 763-5007
Fax: (803) 462-3917
Email: Harry.Feliciano@PalmettoGBA.com
Jurisdiction: J1
MAC Specialty: Internal Medicine, Public Health
Lurvey, Arthur N., M.D.
Palmetto GBA P.O. Box 1476
Medical Review Part B Augusta, GA 30903-1476
Work Phone: (310) 476-5760
Fax: (803) 462-3918
Email: Arthur.Lurvey@PalmettoGBA.com
Jurisdiction: J1
MAC Specialty: Endocrinology. Internal Medicine MAC
Jurisdiction M: North Carolina, South Carolina, Virginia, and West Virginia
Jeter, Elaine, M.D. (PART A)
Palmetto GBA
P.O. Box 100190 AG-300
Columbia, SC 29202-3190
Work Phone: (803) 763-5059
Fax: (803) 935-0199
Email: Elaine.jeter@palmettogba.com
Jurisdiction: J-11 Specialty: Pathology
Pilley, Mark, M.D. (PART B)
Palmetto GBA P.O. Box 100238
Columbia, SC 29202
Work Phone: (803) 763-6203
Fax: (803) 935-0199
Email: Mark.Pilley@bcbssc.com
Jurisdiction: Part A Specialty: Not Available
- Noridian- (10) – MAC Jurisdiction F: Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming
Hecker, Bernice, M.D., M.H.A., FACC
Noridian Administrative Services, LLC
6505 216th Street SW, Suite 200
Mountlake Terrace, WA 98043
Work Phone: (206) 328-4093
Fax: (425) 697-8585
Email: Bernice.hecker@noridian.com
Jurisdiction: J3 MAC; Part A – AK, WA, OR, MN, ID
Specialty: Anesthesiology
Mangold, William (Bill) J., M.D., J.D.
Noridian Administrative Services, LLC
8920 N 23rd Avenue, Suite #1
Phoenix, AZ 85021
Work Phone: (602) 749-2506
Fax: (602) 749-2550
Email: William.mangold@noridian.com
Jurisdiction: J3 MAC Specialty: Plastic Surgery
- Wisconsin Physicians Service: (6) MAC Jurisdiction G: Iowa, Kansas, Missouri, Nebraska
Bussan, Kenneth L., M.D.
Wisconsin Physician Services Corp
1717 W. Broadway, P.O. Box 1787
Madison, WI 53701
Work Phone: (608) 301-2604
Fax: (608) 301-2625
Email: Kenneth.bussan@domino.wpsic.com
Jurisdiction: J-5 MAC Specialty: Internal Medicine MAC Jurisdiction I: Indiana and Michigan
Boren, Stephen D, M.D., M.B.A
Wisconsin Physician Services Corp
111 East Wacker Drive, Suite 950
Chicago, IL 60601
Work Phone: (312) 228-6254
Fax: (312) 228-6280
Email: Stephen.boren@wpisc.com
Jurisdiction: Part B IL, MI, MN Specialty: Emergency Medicine
- National Government Services- (5) MAC Jurisdiction G: Illinois, Minnesota, and Wisconsin
Cunningham, Carolyn, M.D.
National Government Services
8115 Knue Road, INA102-AF10
Indianapolis, IN 46250
Work Phone: (317) 841-4607
Fax: (317) 841-4600
Email: Carolyn.cunningham@anthem.com
Jurisdiction: Part A & B IN, KY; Part A IL, OH
Specialty: Internal Medicine MAC Jurisdiction K: Connecticut, and New York
Cunningham, Carolyn, M.D.
National Government Services
8115 Knue Road, INA102-AF10
Indianapolis, IN 46250
Work Phone: (317) 841-4607
Fax: (317) 841-4600
Email: Carolyn.cunningham@anthem.com
Jurisdiction: Part A & B IN, KY; Part A IL, OH
Specialty: Internal Medicine
- Trailblazer-(7) MAC Jurisdiction H: Colorado, New Mexico, Oklahoma, Texas, Louisiana, Arkansas, Mississippi
Haley, Charles, M.D., M.S., FACP
Trailblazer Health Enterprises, LLC
8330LBJ Freeway, Executive Center III
Dallas, TX 75243-1213
Work Phone: (469) 372-0992
Fax: (469) 372-2649
Email: Charles.Haley@trailblazerhealth.com
Jurisdiction: J4 MAC, TX, CO, NM, OK and Part B VA
Specialty: Internal Medicine, Epidemiology
- CGS Administrators, LLC- (2) MAC Jurisdiction I: Kentucky and Ohio
Oakes, Gary, M.D., FAAFP
CGS Administrators, LLC (formerly CIGNA Government Services)
Two Vantage Way RTG
576 Nashville TN 37228
Work Phone: (615) 782-4565
Fax: (615) 782-4480
Email: gary.oakes@cigna.com
Jurisdiction: J 15 MAC Specialty: Family Practice
- Cahaba GBA, LLC (Cahaba)- (3) MAC Jurisdiction J: Alabama, Georgia, and Tennessee
Humpert, Eddie, M.D., MS
Cahaba GBA P.O. Box 13384
Birmingham AL 35205-3384
Work Phone: (205) 220-1216
Fax: (205) 220-1218
Email: Edward.humpert@cahabagba.com
Jurisdiction: J10 MAC, Part B-MS, RHHI-Midwest
Specialty: General Surgery
- National Heritage Insurance Corporation (NHIC)- (5) MAC Jurisdiction K: Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont
Haug, Craig, M.D. NHIC, Corp
75 Sgt William B. Terry Drive
Hingham, MA 02043
Work Phone: (781) 741-3122
Fax: (781) 741-3211
Email: Craig.haug@hp.com
Jurisdiction: J14 MAC (ME, MA, NH, VT)
Specialty: General Surgery & Transplantation
- Novitas Solutions, Inc.- (5) MAC Jurisdiction L: Delaware, District of Columbia, Maryland, New Jersey, and Pennsylvania
Moynihan, Eileen M., M.D., FACR, FACP
Novitas Solutions, Inc. (formerly Highmark Medicare Services)
1800 Center Street 1A-L3
Camp Hill, PA 17089
Work Phone: (856) 857-5257
Fax: (717) 302-4165
Email: Eileen.moynihan@highmarkmedicareservices.com
Jurisdiction: J-12 MAC Specialty: Rheumatology
Muscalus, Robert, D.O.
Novitas Solutions, Inc. (formerly Highmark Medicare Services)
1800 Center Street 1A-L3 Camp Hill, PA 17089
Work Phone: (717) 302-3030
Fax: (717) 302-4165 Email: robert.muscalus@highmarkmedicareservices.com
Jurisdiction: J-12 MAC
Specialty: Family Practice
- First Coast Service Options, Inc. (FCSO) – (1) MAC Jurisdiction N: Florida Corcoran Jr.,
James J., M.D., M.P.H.
First Coast Service Options, Inc.
532 Riverside Avenue 20T
Jacksonville, FL 32202
Work Phone: (904) 791-8211
Fax: (904) 361-0327
Email: James.Corcoran@fcso.com
Jurisdiction: J9 MAC
Specialty: Internal Medicine, Public Health