Medicare Expands Coverage for Lifesaving Obesity Surgery

GAINESVILLE, Fla. -- After an extensive review of medical evidence that lasted nearly a year, the Centers for Medicare & Medicaid Services (CMS) announced today it will establish a national coverage policy for bariatric surgery to help reduce the significant health risks, including death and disability, associated with obesity.  This new policy will apply to all Medicare recipients including those over 65 and Medicare disabled who are morbidly obese (body mass index or BMI of 35 or greater) with any obesity-related condition or disease and have been previously unsuccessful with the medical treatment of obesity.

The American Society for Bariatric Surgery (ASBS), the largest organization of bariatric surgeons in the world, submitted the request for a national coverage determination (NCD) last May.

"This is a great day in the war against obesity. We expect many private insurers will take their lead from CMS and improve outdated coverage policies that severely restrict or even ban the use of bariatric surgery.  This decision and the data that supports it are overwhelming," said Neil Hutcher, MD, president of the ASBS.  "Obesity is a disease and for many, bariatric surgery is the best treatment. More patients will now have access to a surgery that can prevent, improve, or cure a number of life-threatening obesity related conditions including type 2 diabetes, heart disease, sleep apnea and cirrhosis

of the liver."

Morbid obesity continues to be a growing problem in the U.S. affecting between 8 million and 12 million people.  The number of people who are morbidly obese is growing at double the rate of the rest of the obese population.  In 2005, about 170,000 people had bariatric surgery.

Medicare's previous policy only covered gastric bypass surgery and vertical banded gastroplasty for obesity, and only if the surgery was used to correct an illness "which caused the obesity or was aggravated by the obesity." Coverage was decided from region to region. The new coverage policy is binding on all Medicare contractors and no local coverage policy may be inconsistent.

According to the new policy, CMS will cover methods of bariatric surgery including laparoscopic and open gastric bypass, laparoscopic gastric adjustable banding, open and laparoscopic biliopancreatic diversion and the duodenal switch.  There will be no specific criteria for prior dietary weight reduction programs, recognizing that almost all surgery patients have made numerous attempts to lose weight.

In addition, to optimize quality care, coverage will only be provided if bariatric surgery is performed at an ASBS/Surgical Review Corporation (SRC) Center of Excellence or American College of Surgeons (ACS) Level One Center of Excellence. For a center to receive an ASBS/SRC Center of Excellence designation the hospital or institution must perform at least 125 bariatric surgeries per year collectively and the surgeon must have performed at least 125 bariatric surgeries him or herself and perform at least 50 per year.  The Center must also report long-term patient outcomes and have an on-site inspection to verify all data. In addition, the Center must have a dedicated multi-disciplinary bariatric team that includes surgeons, nurses, medical consultants, nutritionists, psychologists and exercise physiologists.

"The Center of Excellence provision is important.  The evidence shows that the best outcomes and the fewest complications occur in centers with the most experience," said Hutcher.

In July 2004, the Department of Health and Human Services (HHS) eliminated the long-held Medicare policy statement that obesity was not a disease.  In November 2004, a Medicare Coverage Advisory Committee (MCAC) concluded that there is significant scientific evidence supporting the safety and effectiveness of open and laparoscopic weight loss surgery and its ability to improve a number of life-threatening obesity related conditions including diabetes, high blood pressure and high cholesterol in the general adult population.

Approximately 90 percent of Medicare beneficiaries who currently receive bariatric surgery are under 65 and are categorized as disabled under the Social Security Act.

"We believe bariatric surgery will help remove patients from disability status by improving their disabling arthritis, cardiovascular or pulmonary dysfunction.  The cost savings would be significant for Medicare and the health implications would be enormous," said Harvey Sugerman, MD, immediate past president of ASBS.

Source: American Society for Bariatric Surgery (ASBS)