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CMS Clarifies Bariatric Surgery Coverage Criteria


 

Medicare will not cover bariatric surgery for beneficiaries who have type 2 diabetes but do not have a body mass index greater than 35 kg/m

“While recent medical reports claimed that bariatric surgery may be helpful for these patients, [the Centers for Medicare and Medicaid Services] did not find convincing medical evidence that bariatric surgery improved health outcomes for non-morbidly obese individuals,” according to a CMS statement.

Dr. Barry Straube, the agency's director of its Office of Clinical Standards and Quality, said, “Limiting coverage of bariatric surgery in type 2 diabetic patients whose BMI is less than 35 is part of Medicare's ongoing commitment to ensure access to the most effective treatment alternatives with good evidence of benefit, while limiting coverage where the current evidence suggests the risks outweigh the benefits.” The proposal also clarifies that type 2 diabetes is one of the comorbidities that would be acceptable criteria for surgery.

In 2006, the CMS issued a national coverage decision for bariatric surgery in morbid obesity. That decision said that Medicare would cover only three procedures—open and laparoscopic Roux-en-Y gastric bypass surgery, open and laparoscopic biliopancreatic diversion with duodenal switch, and laparoscopic adjustable gastric banding—for beneficiaries who have a BMI greater than 35, have at least one comorbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity.

At that time, the agency then asked for comments on whether Medicare should cover various gastric and intestinal bypass procedures to improve diabetes status among obese, overweight, and nonoverweight diabetes patients.

The proposed decision memo is an outcome of that query; the CMS accepted comments on the memo until mid-December. The agency then has up to 30 days to issue a final decision memo. (The proposed memo is available online at www.cms.hhs.gov/mcd/index_list.asp?list_type=nca

Dr. Jeffrey Mechanick, who cochaired a bariatric surgery guidelines committee for the American Association of Clinical Endocrinologists, said that the CMS was responding to a trend in the medical literature and meeting presentations suggesting that bariatric surgery might be helpful for even those diabetes patients who are not overweight.

“A lot of surgeons began noticing that after bariatric surgery, patients with diabetes had amelioration of their hyperglycemia,” he said. “At first glance, it seems pretty easy—you lose weight and so your diabetes should be getting better. But they found that a lot of the improvement was independent of weight loss; there was something else.”

The theories included two hypotheses: proximal changes, such as factors in the proximal small bowel, and distal changes, such as glucagonlike protein-1 and other factors made by the small bowel in the distal ileum, said Dr. Mechanick, who is also director of metabolic support in the division of endocrinology, diabetes, and bone disease at the Mount Sinai School of Medicine, in New York.

Dr. Mechanick noted that although the CMS currently is not covering the surgery for patients with a BMI under 35, that could change if long-term follow-up data on the procedure became available.

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