CMS Leaves Bariatric Surgery Coverage Up to MACs

Bariatric surgery is risky, and there is little evidence that the risk outweighs the benefits. The toll morbid obesity takes on a person’s health is so great, however, that taking that risk may be worthwhile, the Centers for Medicare & Medicaid Services (CMS) concludes in a final decision memo for bariatric surgery.

For that reason, coverage of stand-alone laparoscopic sleeve gastrectomy (LSG) for the treatment of co-morbid conditions related to obesity in Medicare patients should be left up to Medicare administrative contractors (MACs) to determine on a case-by-case basis, according to CMS.

Not giving MACs total discretion, however, CMS stipulates requirements for coverage.

Medicare beneficiaries must have:

  1. A body mass index (BMI) greater than 35 kg/m²;
  2. At least one co-morbid condition related to obesity (e.g., diabetes, heart disease); and
  3. Been previously unsuccessful with medical treatment for obesity.

Read the final decision memo for complete details.

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