MEDICARE EXPANDS NATIONAL COVERAGE FOR BARIATRIC SURGERY PROCEDURES
The Centers for Medicare & Medicaid Services (CMS) announced today that it is expanding Medicare’s national coverage of bariatric surgery for all Medicare beneficiaries. For seniors, who have experienced high complication rates in some settings, Medicare will cover the procedure only in high-volume centers that achieve low mortality rates.
“Bariatric surgery is not the first option for obesity treatment, but when performed by expert surgeons it is an important option for some of our beneficiaries,” said CMS Administrator Mark B. McClellan, MD, PhD. “While we want to see more evidence on the benefits and risks of this procedure, some centers have demonstrated high success rates and we want to ensure access to the most up-to-date treatment alternatives for our beneficiaries.”
This decision expands coverage beyond a proposal published late last year that would have excluded coverage for bariatric surgery over the age of 65 years. CMS reviewed new data and analyses which demonstrate that surgeons with more experience have similar outcomes for patients of all ages. After reviewing the evidence and considering recommendations of professional societies and other experts in the field, the Agency determined that of the various bariatric surgeries currently available, the evidence indicates that only three types of bariatric surgeries benefit Medicare beneficiaries. Prior to today’s decision, CMS’ only nationally-covered bariatric surgery procedure was gastric bypass surgery. Effective today, the list of nationally-covered procedures now includes open and laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and open and laparoscopic biliopancreatic diversion with duodenal switch. Until other evidence is available, all other bariatric surgical procedures will be nationally non-covered.
According to the National Institutes of Health, approximately 34 percent of Americans are overweight and 27 percent are obese. Overweight and obese persons have an increased risk of a number of diseases compared to those with normal weight and waist circumference, including hypertension, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and certain types of cancers. Because of the relative lack of success of many weight loss programs, persons with obesity have turned to bariatric surgery at an increasing rate. In this national coverage analysis, CMS evaluated the benefits of bariatric
surgery in patients who have one or more of these or other diseases in addition to obesity and found that the benefits of surgery have only been seen in those obese patients who have these problems. Thus, in this decision, Medicare is not covering bariatric surgery in patients who only have the diagnosis of obesity and not one of these other problems.
Also, the Agency determined that the health benefit of bariatric surgery can only be assured in facilities that do large numbers of these procedures performed by highly qualified surgeons. We have evaluated the certification programs of the American College of Surgeons and the American Society for Bariatric Surgery and believe that those facilities recognized by these organizations as Centers of Excellence will be most likely to produce this high level of results. Thus, CMS will cover these procedures only in facilities certified by these organizations. CMS will include a list of certified facilities on its website at www.cms.gov/Center/Special-Topic/Medicare-Coverage-Center.html.
“CMS’ expanded decision draws upon the specific criteria that facilities must meet in order to obtain certification from either the American College of Surgeons or the American Society of Bariatric Surgery. Utilizing these groups’ expertise will ensure that beneficiaries will receive optimal care in a manner that provides the greatest likelihood of successful outcomes from this important procedure,” said Barry M. Straube, MD, CMS’ Acting Chief Medical Officer.
The final decision memorandum is available online at www.cms.gov/Center/Special-Topic/Medicare-Coverage-Center.html