Bariatric surgery gets good review from Medicare panel

Bariatric surgeons are asking CMS for a national coverage determination for the procedure, but more data are needed on older patients.

By David Glendinning — Posted Dec. 6, 2004

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Washington -- Medicare's newly revamped classification of obesity might not lead right to coverage of bariatric surgery for every patient who fits the bill in terms of body mass. But a largely positive report on the procedure from experts advising the government indicates that a new federal benefit standard could be appropriate for at least some of them.

Surgery proponents got a boost from the Medicare Coverage Advisory Committee, which at a recent meeting ruled that current scientific evidence shows bariatric surgery to be more effective than nonsurgical interventions in sustaining weight loss, ensuring long-term survival, and reducing comorbidities for patients younger than 65 who have obesity-related illnesses.

The American Society for Bariatric Surgery immediately announced its intention to seek a national determination that would standardize coverage of the treatment for enrolled seniors and people with disabilities.

"We are pleased that the MCAC panel has so decisively affirmed the safety and effectiveness of open and laparoscopic weight-loss surgery, and we look forward to working with Medicare to help them provide the best coverage and gather the best data on individuals 65 and older," said the society's president, Harvey Sugerman, MD.

The group's request will prompt the Centers for Medicare & Medicaid Services to embark on a roughly year-long review process in which the agency will take into account the advisory committee's report, which is nonbinding.

Medicare now covers bariatric surgery as long as the beneficiary has been diagnosed with a certain condition that stems from morbid obesity.

Although federal officials list diabetes and hypertension as two possible comorbidities that can trigger coverage, individual Medicare carriers draft the final eligibility list at the local level.

"That is very arbitrary," said Jeff Allen, MD, a bariatric surgeon at the University of Louisville School of Medicine.

Supporters of a national coverage determination say establishing one set of rules for all carriers would produce a more consistent application of the treatment, save more lives and lower medical costs over the long run.

Maybe not for everyone

Despite its general vote of confidence for the procedure, the advisory committee was less impressed with the availability of evidence suggesting that surgery could be appropriate for a greater range of beneficiaries.

Part of the rationale behind pushing for a new coverage determination is a desire to offer the expensive procedure to morbidly obese individuals who have no related illnesses. Panel members ruled that findings to support such an application are insufficient. Their conclusion is based on reports from physicians that such patients virtually do not exist.

"You'd be hard-pressed to find surgeons or physicians in general who take care of patients with a [body mass index] greater than 40 who don't have comorbidities," said David Flum, MD, MPH, a bariatric surgeon at the University of Washington School of Medicine.

It is also unclear whether the surgery would be an effective option for elderly patients compared with younger ones, the committee decided. Roughly 90% of the Medicare patients who receive the surgery are younger than 65 and have disabilities. Panel members and physician witnesses were nearly unanimous in calling for more scientific data on weight-loss surgery for seniors.

"Because there are age-related differences in underlying physiology in general and fat distribution in particular, one should be cautious about generalizing the findings in the younger population to those above 65," said Josef Fischer, MD, speaking on behalf of the American College of Surgeons.

Meanwhile, bariatric surgeons treating both Medicare and non-Medicare patients are eager to see what, if anything, the government will do. While some private insurers recently have begun paying for bariatric surgery, others have suspended their coverage, citing mortality risks. Several experts at the meeting said that CMS' issuance of a national coverage determination likely would spur many insurers to restore or add weight-loss surgery to their list of benefits.

"The country is watching," said Barry Fisher, MD, chief of surgery at the University of Nevada School of Medicine. "CMS must come out with a clear and unencumbered statement of coverage."

Some consider expanded Medicare coverage of bariatric procedures to be the next step in the evolution of obesity treatment. In what many saw as a major development, CMS in July removed language from the Medicare Coverage Issues Manual stating that obesity is not an illness.

But the agency has stopped short of expressly identifying morbid obesity as a disease. Steve Phurrough, MD, director of the CMS Coverage and Analysis Group, suggested at the meeting that the current classification will stay intact regardless of whether the government expands or restricts its bariatric surgery policy.

Responding to estimates that two-thirds of U.S. residents are overweight or obese, the American Medical Association has identified the problem as an epidemic but has similarly avoided calling it a disease.

The year-long determination process will touch on patient safety issues that could determine how narrowly the agency crafts any policy change. Dr. Phurrough suggested that federal officials could provide more coverage only if the surgery takes place at one of the centers for excellence being developed by the bariatric surgery society.

CMS also might extend coverage through a demonstration project or require physicians performing the procedure to record their patients' outcomes in a national registry.

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Trimming the fat

Roughly 150,000 bariatric surgeries were performed in the U.S. this year. Surgeons use one of three techniques to help patients drop the pounds.

Gastric banding: Installing an adjustable band around the top portion of the stomach allows the patient to feel full after eating a smaller amount.

Roux-en-Y gastric bypass: Creating a small stomach pouch that attaches directly to the small intestine restricts food intake and causes malabsorption of fats.

Biliopancreatic diversion: Removing part of the stomach and attaching the remainder to the final segment of the small intestine restricts food intake and causes malabsorption of fats.

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