Medicare Approval Question

[Susan Mary 20]

Hi....I am waiting for Medicare to approve my gastric sleeve surgery request. I have severe sleep apnea, a BMI of 36, am pre-diabetic, have osteo-arthritis, a fused right ankle and GERD. Has anyone else had sleeve surgery through Medicare with similar issues? Thanks!

[Sharon1964 2,530]

Medicare has a National Coverage Determination (NCD) that covers bariatric surgery. This means it does not matter which state you live in, the coverage and requirements are the same. If you're googling, it's NCD Number 100.1 (one hundred point one). Here is the NCD:

Item/Service Description

A. General

Bariatric surgery procedures are performed to treat comorbid conditions associated with morbid obesity. Two types of surgical procedures are employed. Malabsorptive procedures divert food from the stomach to a lower part of the digestive tract where the normal mixing of digestive fluids and absorption of nutrients cannot occur. Restrictive procedures restrict the size of the stomach and decrease intake. Surgery can combine both types of procedures.

The following are descriptions of bariatric surgery procedures:

1. Roux-en-Y Gastric Bypass (RYGBP)

The RYGBP achieves weight loss by gastric restriction and malabsorption. Reduction of the stomach to a small gastric pouch (30 cc) results in feelings of satiety following even small meals. This small pouch is connected to a segment of the jejunum, bypassing the duodenum and very proximal small intestine, thereby reducing absorption. RYGBP procedures can be open or laparoscopic.

2. Biliopancreatic Diversion with Duodenal Switch (BPD/DS)

BPD achieves weight loss by gastric restriction and malabsorption. The stomach is partially resected, but the remaining capacity is generous compared to that achieved with RYGBP. As such, patients eat relatively normal-sized meals and do not need to restrict intake radically, since the most proximal areas of the small intestine (i.e., the duodenum and jejunum) are bypassed, and substantial malabsorption occurs. The partial BPD/DS is a variant of the BPD procedure. It involves resection of the greater curvature of the stomach, preservation of the pyloric sphincter, and transection of the duodenum above the ampulla of Vater with a duodeno-ileal anastamosis and a lower ileo-ileal anastamosis. BPD/DS procedures can be open or laparoscopic.

3. Adjustable Gastric Banding (AGB)

AGB achieves weight loss by gastric restriction only. A band creating a gastric pouch with a capacity of approximately 15 to 30 cc’s encircles the uppermost portion of the stomach. The band is an inflatable doughnut-shaped balloon, the diameter of which can be adjusted in the clinic by adding or removing saline via a port that is positioned beneath the skin. The bands are adjustable, allowing the size of the gastric outlet to be modified as needed, depending on the rate of a patient’s weight loss. AGB procedures are laparoscopic only.

4. Sleeve Gastrectomy

Sleeve gastrectomy is a 70%-80% greater curvature gastrectomy (sleeve resection of the stomach) with continuity of the gastric lesser curve being maintained while simultaneously reducing stomach volume. It may be the first step in a two-stage procedure when performing RYGBP. Sleeve gastrectomy procedures can be open or laparoscopic.

5. Vertical Gastric Banding (VGB)

The VGB achieves weight loss by gastric restriction only. The upper part of the stomach is stapled, creating a narrow gastric inlet or pouch that remains connected with the remainder of the stomach. In addition, a non-adjustable band is placed around this new inlet in an attempt to prevent future enlargement of the stoma (opening). As a result, patients experience a sense of fullness after eating small meals. Weight loss from this procedure results entirely from eating less. VGB procedures are essentially no longer performed.

Indications and Limitations of Coverage

B. Nationally Covered Indications

Effective for services performed on and after February 21, 2006, Open and laparoscopic Roux-en-Y gastric bypass (RYGBP), open and laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS), and laparoscopic adjustable gastric banding (LAGB) are covered for Medicare beneficiaries who have a body-mass index ≥ 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. These procedures are only covered when performed at facilities that are: (1) certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center (program standards and requirements in effect on February 15, 2006); or (2) certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (program standards and requirements in effect on February 15, 2006).

Effective for services performed on or after February 12, 2009, the Centers for Medicare & Medicaid Services (CMS) determines that Type 2 diabetes mellitus is a co-morbidity for purposes of this NCD.

A list of approved facilities and their approval dates are listed and maintained on the CMS Coverage Web site at http://www.cms.gov/Medicare/Medicare-General-Information/MedicareApprovedFacilitie/Bariatric-Surgery.html, and published in the Federal Register.

C. Nationally Non-Covered Indications

The following bariatric surgery procedures are non-covered for all Medicare beneficiaries:

• Open adjustable gastric banding;
• Open and laparoscopic sleeve gastrectomy; and,
• Open and laparoscopic vertical banded gastroplasty.

The two previous non-coverage determinations remain unchanged - Gastric Balloon (Section 100.11) and Intestinal Bypass (Section 100.8).

Edited March 4, 2015 by Sharon1964

[Sharon1964 2,530]

(see next message)

Edited March 4, 2015 by Sharon1964

[Sharon1964 2,530]

More info: When there is a National Coverage Determination, there is sometimes a Local Coverage Determination (LCD), which overrides the NCD. I did find an LCD for one Medicare geographic area, that does cover VSG. Without knowing your city or state, I don't know if there is an LCD for your area.