Morbid obesity is recognized as a significant health risk associated with physical problems that may increase morbidity and mortality among the Medicare population. According to the U.S. Preventive Services Task Force, “obesity is a risk factor for major causes of death, including cardiovascular disease, numerous types of cancer, and diabetes, and is linked with markedly diminished life expectancy.” The surgical management of morbid obesity, bariatric surgery, is a treatment that may result in dramatic weight loss. Several different surgical procedures have been used for people with morbid obesity, including biliopancreatic diversion, Roux-en-Y gastric bypass, and gastric banding.
The CMS policy on obesity can be found in Section 40.5 of the NCD Manual: “Obesity may be caused by medical conditions such as hypothyroidism, Cushing's disease, and hypothalamic lesions, or can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension. Services in connection with the treatment of obesity are covered when such services are an integral and necessary part of a course of treatment for one of these medical conditions. However, program payment may not be made for treatment of obesity unrelated to such a medical condition since treatment in this context has not been determined to be reasonable and necessary.”
Currently Section 100.1 of the National Coverage Determination (NCD) Manual states: Gastric bypass surgery which is a variation of the gastrojejunostomy, is performed for patients with extreme obesity. Gastric bypass surgery for extreme obesity is covered under the program if (1) it is medically appropriate for the individual to have such surgery; and (2) the surgery is to correct an illness which caused the obesity or was aggravated by the obesity.
Intestinal Bypass Surgery (NCD Manual Section 100.8) and Gastric Balloon for Treatment of Obesity (NCD Manual Section 100.11 are not covered by Medicare since the safety of these procedures for the treatment of obesity has not been demonstrated.
A Medicare Coverage Advisory Committee discussing bariatric surgery meeting was held November 4, 2004. The summary, transcript and supporting documents can be found at https://www.cms.hhs.gov/mcd/viewmcac.asp?where=index&mid=26.
CMS has received a request to review the evidence for coverage of the following surgical procedures; Roux-en-Y Gastric Bypass (open and laparoscopic); Adjustable Gastric Banding (open or laparoscopic); and Biliopancreatic Diversion (with or without duodenal switch, both open and laparoscopic; Vertical Banded Gastroplasty (open or laparoscopic).