American Society for Metabolic and Bariatric Surgery Frequently Asked Questions Regarding Centers for Medicare and Medicaid Services Coverage for Laparoscopic Sleeve Gastrectomy

| September 18, 2012

This article contains a complimentary physician handout. To downloadable PDF of of this handout click HERE.

by John M. Morton, MD, MPH, FACS, FASMBS
Dr. Morton is from the Section of Bariatric and Minimally Invasive Surgery, Stanford University, Stanford, California. He is also Chairperson of ASMBS Access to Care Committee

Bariatric Times. 2012;9(9):14–15

The Centers for Medicare and Medicaid Services (CMS) Laparoscopic Sleeve Gastrectomy National Care Determination was completed on June 27, 2012. The American Society for Metabolic and Bariatric Surgery asks that you please review the below Frequently Asked Questions. Please keep in mind that the decision allows for local Medicare administrators to approve coverage. Until clarity regarding local CMS coverage is achieved, performance of a laparoscopic sleeve gastrectomy (LSG) in a Medicare patient has potential for no reimbursement for surgeon and hospital alike. It is prudent to seek out local regional Medicare administrators regarding their policy prior to surgery and if you are denied after surgery, always request a peer-to-peer review. Also, you should also approach your own facility to review your own institutional approach to LSG coverage.

Q: What is the CMS Decision?

On June 27, 2012, the Centers for Medicare and Medicaid Services (CMS) released their decision on coverage for the laparoscopic sleeve gastrectomy (LSG). The final decision will allow laparoscopic sleeve gastrectomy to be covered by intermediary Medicare administrators as a stand-alone procedure at their discretion. Final text is as follows:
CMS Conclusions and Rationale for Decision: The available evidence does not clearly and broadly distinguish the patients who will experience an improved outcome from those who will derive harm such as postoperative complications or adverse effects from LSG. However, taking into consideration the seriousness of obesity, the possibility of benefit in highly selected patients in qualified centers, we believe that local Medicare contractor determination on a case-by-case basis balances these considerations in the interests of our beneficiaries. Our local contractors are in a better position to consider characteristics of individual beneficiaries and the performance of eligible bariatric centers within their jurisdictions. Therefore, Medicare Administrative Contractors acting within their respective jurisdictions will make an initial determination of coverage under section 1862(a)(1)(A) and we are not making a national coverage determination under section 1869(F).

Q: How did the CMS Decision Happen?

The following is a timeline of the CMS decision.

•    September 2011: CMS opens this national coverage determination reconsideration request to review the new evidence for laparoscopic sleeve gastrectomy. CMS is requesting public comment on whether there is adequate evidence, including clinical trials, for evaluating health outcomes of laparoscopic sleeve gastrectomy for the indications listed in the current Bariatric Surgery for the Treatment of Morbid Obesity National Coverage Determination. After considering the public comments and reviewing relevant evidence, we will release a proposed decision memorandum. Instructions for submitting public comments can be found at http://www.cms.hhs.gov/InfoExchange/02_publiccomments.asp#TopOfPage

•    March 2012: Posted proposed decision memo. The full memo can be found at http://asmbs.org/2012/04/cms-and-sleeve-gastrectomy-call-to-action-for-all-members/

•    June 2012: Posted final decision memo. The full memo can be found at http://asmbs.org/2012/06/access-to-care-alert-the-cms-final-decision/

Q: What are Medicare Regional Administrators?

Medicare Administrative Contractors (MACs) are new entities created by CMS to integrate the administration of Medicare Parts A and B from the former fiscal intermediaries and carriers. For a full  list of MACs by jurisdiction, see Reader Handout on facing page, Medicare Administrative Contractors by Jurisdiction.

Also, A full article on this topic can be found at http://asmbs.org/2012/07/
potomac-current-july-2012/

Q: Can I start performing sleeve gastrectomy in medicare patients?

Further clarification is needed from your regional Medicare Administrator. This may take months. The Access to Care Committee will coordinate with your regional champion State Access to Care Representatives (STARs) to ensure you can perform sleeve gastrectomy and be reimbursed. Prior to an official decision, centers have a risk of not being reimbursed when performing sleeve gastrectomy. There is always an option to appeal.

Q: If Denied Reimbursement from CMS When Performing LSG, How Do I Appeal?

Contact your local Medicare administrator and use the two letters provided with this article, which can be downloaded from www.bariatrictimes.com, to formulate your written response. Always ask for a peer-to-peer review—you have the facts on your side and can be persuasive. Always get your patients involved.

Q: Who is my State Access to Care Representative?

See Reader Handout on facing page, Medicare Administrative Contractors by Jurisdiction. to find the STAR in your area.

Q: Which patients should receive sleeve gastrectomies?
The individual decision regarding which surgery for which patient is best left to surgeon and patient alike. Please consult http://s3.amazonaws.com/publicASMBS/GuidelinesStatements/PositionStatement/ASMBS-SLEEVE-STATEMENT-2011_10_28.pdf for further information

Also, CMS has determined slightly different criteria for Medicare coverage, mainly that any bariatric surgery patient both at least on comorbidity and a body mass index (BMI) more than 40kg/m2. There is no current approved list of comorbidities. You may have to do a peer-to-peer review regarding comorbidity adequacy. In general, more comorbidities equal better chance for coverage, particularly diabetes, hypertension, hyperlipidemia, or sleep apnea. Also, CMS sleeve gastrectomy must be performed at CMS-accredited centers.

Medicare Administrative Contractors acting within their respective jurisdictions may determine coverage of stand-alone LSG for the treatment of comorbid conditions related to obesity in Medicare beneficiaries only when all of the following conditions (A to C) are satisfied:
A. The beneficiary has a BMI of 35kg/m2 or more

B. The beneficiary has at least one comorbidity related to obesity

C.The beneficiary has been previously unsuccessful with medical treatment for obesity.

Q: What resources are available to me?

•    Access to Care Chair, John Morton, MD, MPH, FASMBS; E-mail: morton@stanford.edu

On the web:

1.    ASMBS letter to CMS July 2012

http://bit.ly/LCwefP

2.    Laparoscopic Sleeve Gastrectomy Selected Bibliography

http://bit.ly/OcUkv2

3.    CMS National Coverage Determination (NCD) for Bariatric Surgery for Treatment of Morbid Obesity (100.1)

http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=57&bc=AgAAgAAAAAAA&ncdver=3

4.    CMS and Sleeve Gastrectomy: Call to Action for All Members

http://asmbs.org/2012/04/cms-and-sleeve-gastrectomy-call-to-action-for-all-members/

5.    ASMBS Response to CMS Sleeve Coverage Decision
http://s3.amazonaws.com/publicASMBS/Emails/ASMBS-Response-to-CMS-Sleeve-Coverage-
Decision.pdf

6.    ASMBS Access to Care Alert—The CMS Final Decision http://asmbs.org/2012/06/access-to-care-alert-the-cms-final-decision/

7.    Sleeve Gastrectomy ICD-9 Coding and DRG Mapping. New Ruling Published
http://s3.amazonaws.com/publicASMBS/top5/august2011/Sleeve%20Gastrectomy%20ICD%20code%20-%20Ponce.pdf

8.    ASMBS Updated Position Statement on Sleeve Gastrectomy as a Bariatric Procedure Revised 10/28/2011

http://s3.amazonaws.com/
publicASMBS/GuidelinesStatements/PositionStatement/ASMBS-SLEEVE-STATEMENT-2011_10_28.pdf

Acknowledgment: The author would like to thank Jennifer Wynn for her assistance with this article.

FUNDING: No funding was provided.

DISCLOSURES: The author reports no conflicts of interest relevant to the content of this article.

Category: News and Trends, Past Articles

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