Government

Disabled patients will get bariatric surgery coverage

The bariatric surgery society calls for Medicare to rethink excluding seniors from coverage.

By David Glendinning — Posted Dec. 19, 2005

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Washington -- A campaign to convince Medicare to cover weight-loss surgery for morbidly obese beneficiaries has achieved partial success, with the government proposing to cover certain patients who are younger than 65.

The Centers for Medicare & Medicaid Services last month released a proposed national coverage decision that would direct Medicare to help pay for the surgery for enrollees with disabilities. Patients would qualify for federal help if they have a body mass index of 35 or greater, have at least one obesity-related comorbidity and have unsuccessfully tried nonsurgical medical interventions.

CMS agreed with bariatric surgeons that gastric banding or Roux-en-Y gastric bypass procedures are necessary and safe for some patients for whom less radical courses of action have not worked.

"While the best proven 'treatment' is a nutritious diet and regular exercise, and medical treatments are also available, some beneficiaries may significantly reduce their health risks through surgery," said CMS Administrator Mark McClellan, MD, PhD.

The change in policy, which would take effect after the agency issues a final determination early next year, is expected to increase the frequency with which the government pays for weight-loss procedures. Medicare covered nearly 8,000 bariatric surgeries out of the roughly 150,000 performed in the United States last year, but only through local carriers that had determined on their own that the patients' comorbidities -- such as diabetes or hypertension -- could be treated only in this way.

By not addressing obesity itself as a condition, the current system lacks the needed consistency for physicians and patients that a national coverage decision will impose, according to the American Society for Bariatric Surgery, which requested a federal policy.

"This new [national decision] is a major improvement for the care of the morbidly obese Medicare patient," write ASBS President Neil Hutcher, MD, and Immediate Past President Harvey J. Sugerman, MD, in a letter to CMS.

"Prior to this, the availability of the surgery varied from region to region, and the provider could not be assured of reimbursement until after the procedure was performed and the charges submitted," they wrote.

The government's conclusions on the safety of the procedures are also likely to have ramifications in the private sector. Insurers often follow the government's lead in determining what medical services are appropriate to cover, and some payers have delayed or suspended coverage of bariatric surgery because of questions about its risks for patients.

Seniors may be out of luck

Medicare officials agreed that enough clinical evidence exists to support covering the surgery for morbidly obese patients who are enrolled in the program because they're disabled, but CMS balked at extending the procedures to senior beneficiaries.

A CMS memo to physicians cited a study showing that mortality rates among elderly patients receiving the surgery were significantly higher than for patients younger than 65. A specific statement of noncoverage for older Medicare patients because of such safety concerns would mean that seniors still wanting the surgery would need to pay for the relatively expensive procedures entirely on their own, even in areas where they now can apply for federal help.

"We felt that the medical literature does not yet support coverage for that population," said Barry Straube, MD, acting chief medical officer at CMS. "It doesn't mean that it never will."

Most patients who have been able to get Medicare-covered bariatric surgery to treat their obesity-related conditions are in the program because they are disabled, not because they are older than 65. But morbidly obese seniors who are good candidates for the procedures, roughly 200 of whom now receive the surgery in a given year, are largely out of luck when it comes to getting the best treatment options, Drs. Hutcher and Sugerman said. These patients can try to come up with the more than $10,000 that the typical bariatric surgery costs or else continue to take their chances with nonsurgical treatments that have not worked.

The bariatric surgery society leaders cited other studies showing that seniors' mortality rates went down significantly when the surgeries were performed at one of the group's centers of excellence, which become accredited when they perform a certain number of the procedures per year.

"Patients [65 or older] should be given the option of choosing surgery with a thorough preoperative risk-benefit discussion in a validated center of excellence," the ASBS letter states. "Had this not been available, [past] patients ... who were incapacitated by their severe obesity would not have been able to receive the benefits of bariatric surgery."

A more limited group of seniors, however, might be able to get Medicare's help with the surgery next year, as long as their doctors are willing to do some extra work on their behalf. CMS is asking for comments on how the agency can extend coverage to patients older than 65 whose doctors report their clinical outcomes to the government.

Such coverage might be appropriate through a Medicare-sponsored clinical trial, Dr. Straube said. CMS is also seeking comments on whether all federally covered bariatric surgeries should be allowed only at facilities that perform a certain number of the procedures per year.

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ADDITIONAL INFORMATION

What's covered, what's not

Medicare officials have proposed covering bariatric surgery, starting early next year, for morbidly obese beneficiaries who are younger than 65 and have at least one obesity-related comorbidity.

Covered

  • Adjustable gastric banding, laparoscopic
  • Roux-en-Y gastric bypass, open or laparoscopic

Not covered

  • Adjustable gastric banding, open
  • Biliopancreatic diversion with or without duodenal switch
  • Vertical banded gastroplasty
  • Sleeve gastrectomy

Source: Centers for Medicare & Medicaid Services

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External links

Centers for Medicare & Medicaid Services proposed decision memo on bariatric surgery coverage (link)

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