04/2006 - Medicare will cover open and laparoscopic Roux-en Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB) and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) if certain criteria are met and the procedure is performed in an approved facility. Effective date: 02/21/2006 (TN 54) (CR5013).
- 05/30/2006 for physician claims billed to the carrier
- 10/02/2006 for hospital claims billed to the FI
04/2009 - Effective for services performed on and after February 12, 2009, CMS determines that open and laparoscopic Roux-en-Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) in Medicare beneficiaries who have type 2 diabetes mellitus (T2DM) and a BMI less than 35 are not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act, and therefore are not covered. Effective date: 02/12/2009 Implementation date: 05/18/2009 (TN 100) (CR6419).
11/2012 Effective for claims with dates of service on or after June 27, 2012, 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. Effective date: 06/27/2012 Implementation date: 12/10/2012. (TN 148) (CR8028).
01/2013 Transmittal 148, dated November 9, 2012 is rescinded and replaced by Transmittal 150, dated January 29, 2013. The Business Requirement 8028.1 has been updated to include the correct responsibility FI that was previously omitted. All other information remains the same. (TN 150) (CR8028).