CMS has announced their final decision on whether Medicare will cover the sleeve gastrectomy. Having proposed in April to only allow coverage of the sleeve as part of a randomized, controlled trial, CMS changed their decision after the final public comment period. CMS announced that they are allowing regional CMS contractors to decide on an individual basis if the sleeve should be covered by Medicare.
The decision states:
“Medicare Administrative Contractors acting within their respective jurisdictions may determine coverage of stand-alone laparoscopic sleeve gastrectomy (LSG) for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries only when all of the following conditions A-C are satisfied.”
Condition A is that the patient have a BMI of 35 or greater. Condition B is that the patient has at least one obesity-related comorbidity. Common comorbidities include: diabetes, high cholesterol, high blood pressure, sleep apnea, heartburn, and depression. And the final condition – Condition C – is that the patient has previously tried medical weight loss, and has been unsuccessful.
We spoke with Dr. Matt Brengman, Chair of the Insurance Committee for ASMBS, who told us “The medicare decision is quite positive for our patients. It is certainly much better than the proposed decision announced in March. That proposed decision would have limited access to this proven procedure to a few patients in a few sites, and required at least 3 year follow-up prior to reconsideration. As the majority of Medicare beneficiaries that get bariatric surgery are under 65 years old, randomized clinical trials are not necessary (as they have already been performed). The decision to leave coverage to the local contractors has precedent. Before the National Care Decision (NCD) for bariatrics, all of bariatric surgery was handled this way.” According to Dr. Brengman, CMS’ decision has both positives and negatives: “The positive is coverage without the lengthy process of an NCD; the down side is that the coverage is unlikely to be uniform around the country. In the case of sleeve gastrectomy, this may lead patients to doctor-hop to get the surgery and then return home.”
The President of the ASMBS (American Society for Metabolic and Bariatric Surgery), Dr. Jaime Ponce, told us “I am very pleased and gratified that CMS has recognized the true value and compelling need for coverage of this procedure. The ASMBS will immediately initiate the formal pathway for coverage with each regional CMS intermediary by reiterating the arguments for coverage. The overwhelming response from patients, surgeons and integrated health members, along with the strong evidence base for LSG, provided CMS with a persuasive argument for LSG coverage.” The next step for ASMBS, Dr. Ponce says, is connecting with each individual intermediary. “This decision will open the door to widespread coverage based on the strong, available evidence.”
What are the next steps for surgeons and patients? Dr. John Morton, who serves as Chair of the Access to Care Committee of the ASMBS told us, “The ASMBS – through our Access to Care Committee – will work directly with the regional Medicare Administrators to ensure that all of our surgeons have the ability to perform life-saving interventions for these patients. The CMS decision demonstrates that we work best when we work together in common purpose with evidence for the safety and welfare of our patients.” For Medicare patients hoping to get the sleeve gastrectomy, Dr. Brengman encourages them to make sure they are heard: “Patients hold the key to access. If patients strongly desire sleeve gastrectomy in a particular region they should voice their support to their local contractor and demand coverage. Patients can look at their explanation of benefits statement to find out who their contractor is.”
You can learn more about the sleeve gastrectomy here.