Bariatric surgery available to more Medicare patients

Outpatient surgery programs will be able to offer the outpatient lap band procedure to Medicare beneficiaries following an announcement that the procedure now is covered by the Centers for Medicare & Medicaid Services (CMS).

On Feb. 21, 2006, CMS announced the establishment of a national coverage policy that will standardize coverage for all Medicare contractors and expanded the types of bariatric surgery that are covered.

CMS will cover open and laparoscopic gastric bypass, and open and laparoscopic biliopancreatic diversion with a duodenal switch, but the new policy also covers lap band surgery, which is used in outpatient settings, says Harvey Sugerman, MD, professor emeritus of surgery at Virginia Commonwealth University in Richmond and immediate past president of the American Society for Bariatric Surgery (ASBS).

Coverage also will be easier to determine because this is a national coverage policy, says Sugerman. CMS’ prior policy restricted coverage of bariatric surgery to procedures that were necessary to correct an illness that was caused by, or aggravated by, the patient’s obesity. While patients still must have a body mass index ≥ 35 and have at least one comorbidity related to obesity, the nationally standardized guidelines will eliminate coverage decisions that varied from region to region, he points out. Previously, regional Medicare contractors set their own coverage parameters, and it was difficult for surgeons and surgery programs to predict reimbursement, he says.

Because Medicare reimbursement is determined after a procedure is complete, there have been many instances in which a surgeon proceeded with the procedure, expecting reimbursement based upon his or her interpretation of coverage policies, only to find out that the regional Medicare contractor denied payment to the surgeon and the hospital, Sugerman explains. "A standardized, national policy will make it more likely that the surgeon and the surgery program know that the surgery will be covered."

Another component of the CMS policy is that coverage will only be provided if the surgery is performed at an ASBS/Surgical Review Corp. (SRC) Center of Excellence or an American College of Surgeons 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 himself or herself, and perform at least 50 per year. The center also must report long-term patient outcomes and have an on-site inspection to verify all data. In addition, the center must have a dedicated multidisciplinary bariatric team that includes surgeons, nurses, medical consultants, nutritionists, psychologists, and exercise physiologists.

The Center of Excellence is an important provision to ensure quality patient care, Sugerman says. "At this time, ASBS has several outpatient surgery programs going through our Outpatient Centers of Excellence program, so we will have those programs accredited within the next six months," he says. (For more information about the ASBS/SRC Center of Excellence program, visit www.surgicalreview.org.)

"This is a win-win-win situation for Medicare, obesity patients, and health care providers," says Sugerman. "Many Medicare patients who undergo bariatric procedures are younger than 65 but are on Medicare due to disability related to obesity," he says. "By making the surgery available to more patients, we will not only see a drop in the health care bills as these patients are better able to deal with other conditions such as diabetes, pulmonary dysfunction, or arthritis, but we will also see more of them return to work and moving off Medicare."

The final decision CMS memorandum can be found at: www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=160.