Medicare Will Not Pay for Bariatric Surgery to Treat
Diabetes Unless Patient Hits BMI of 35
CMS seeks comments on this revision of the bariatric
surgery coverage
Nov. 17, 2008 – Medicare will draw the line at a
body-mass index (BMI) of 35 to determine if a senior citizen is morbidly
obese and qualified to receive coverage for bariatric surgery as a
treatment for beneficiaries with type 2 (or non-insulin-dependent)
diabetes, according to an announcement today by the Centers for Medicare
& Medicaid Services (CMS).
Following an "extensive" evidence review, CMS says
it proposes to revise its existing coverage policy for bariatric
surgery. The proposed decision notes that type 2 diabetes is one of the
co-morbidities CMS would consider in determining whether bariatric
surgery would be covered for a Medicare beneficiary who is morbidly
obese. An individual with a body-mass index (BMI) of at least 35 will be
considered morbidly obese.
CMS also proposes to not cover bariatric surgery
when it is used to treat type 2 diabetes in a beneficiary with a BMI
below 35.
"Bariatric surgery is a viable option for many
morbidly obese patients who have not been successful with other weight
loss programs," said CMS Acting Administrator Kerry Weems.
"CMS wants to be sure that these patients have
access to a solution to help them achieve a healthier weight and avoid
some of the most serious complications of type 2 diabetes."
In 2006, CMS expanded coverage of bariatric surgery
for Medicare beneficiaries who received surgery in high-volume centers
from highly qualified surgeons (as certified by the American College of
Surgeons or the American Society for Bariatric Surgery, and as reported
on the Medicare coverage Web site).
Seniors with limited resources may be eligible for
extra help to pay monthly premiums, annual deductibles and prescription
co-payments
By Oscar Garcia Public Affairs Specialist, Social Security Administration
Nov. 17, 2008 - The open season for enrollment in
the Medicare Part D prescription drug program opened on November 15 and
will run to December 31. Newly eligible Medicare beneficiaries and
current beneficiaries, who are considering changes to their Medicare
Part D plan, can do so during this period.
Read more...
To be considered for coverage, Medicare
beneficiaries must have a BMI of 35 or higher, and must have exhibited a
serious health condition in addition to morbid obesity, such as
hypertension, coronary artery disease, or osteoarthritis.
With the 2006 decision, CMS covered four types of
bariatric surgery procedures: gastric bypass, open and laparoscopic
Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and
open and laparoscopic biliopancreatic diversion with duodenal switch. No
other bariatric surgery procedure is currently covered.
After a review of the medical evidence available on
bariatric surgery, CMS today proposes to not cover bariatric surgery for
patients who do not meet the definition of morbid obesity, but do have
type 2 diabetes.
While recent medical reports claimed that bariatric
surgery may be helpful for these patients, CMS did not find convincing
medical evidence that bariatric surgery improved health outcomes for
non-morbidly obese individuals.
CMS seeks comments from the public about this
evidence and its implications for coverage, and about which groups of
patients should be covered for this surgery.
"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,"
said Barry Straube, M.D., CMS chief medical officer and director of the
agency's Office of Clinical Standards & Quality.
Today's proposed decision memorandum is available
on CMS' Coverage Web site at
http://www.cms.hhs.gov/center/coverage.asp. CMS encourages the
public to respond to the agency's proposed decision by submitting public
comments directly to the Coverage Web site. Comments will be accepted
for 30 days following the posting of the proposed decision memorandum.
After careful consideration of the public comments, CMS will issue a
final decision memorandum within 90 days of the proposed decision.
Keep up with the latest news for senior citizens, baby
boomers
Nov. 17, 2008 – Medicare will draw the line at a
body-mass index (BMI) of 35 to determine if a senior citizen is morbidly
obese and qualified to receive coverage for bariatric surgery as a
treatment for beneficiaries with type 2 (or non-insulin-dependent)
diabetes, according to an announcement today by the Centers for Medicare
& Medicaid Services (CMS).