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LSG coverage

CMS allows LSG procedures in some Medicare centres

Decision allows limited, not national coverage
Administrators in a better position to consider characteristics of individual beneficiaries
ASMBS “confident” coverage will be achieved

The Centers for Medicare and Medicaid Services (CMS) has announced its decision on coverage for the laparoscopic sleeve gastrectomy (LSG). The final decision will allow LSG to be covered by intermediary Medicare administrators as a stand-alone procedure at their discretion.

Reversal

The decision is a reversal of their proposed coverage, published in April 2012, to only allow coverage of LSG as part of a randomised, controlled trial. However, the announcement falls short of a national coverage determination.

The CMS’ decision stated that Medicare Administrative Contractors acting within their respective jurisdictions may determine coverage of stand-alone LSG for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries only when all of the following conditions 1-3 are satisfied:

  1. The beneficiary has a BMI ≥35 kg/m2,
  2. The beneficiary has at least one co-morbidity related to obesity, and
  3. The beneficiary has been previously unsuccessful with medical treatment for obesity.

The decision statement also added that the CMS believes that the available evidence “does not clearly and broadly distinguish the patients who will experience an improved outcome from those who will derive harm such as postoperative complications or adverse effects from LSG.”

However, in its statement the CMS does acknowledge the seriousness of obesity and the possible benefits of LSG in highly selected patients in qualified centres, and has therefore decided that local Medicare contractor determination “on a case-by-case basis balances these considerations in the interests of our beneficiaries.”

The statement concluded that: “Our local contractors are in a better position to consider characteristics of individual beneficiaries and the performance of eligible bariatric centres within their jurisdictions. Therefore, Medicare Administrative Contractors acting within their respective jurisdictions will make an initial determination of coverage under section 1862(a)(1)(A) and we are not making a national coverage determination under section 1869(F).”

ASMBS response

In a response posted on the their website, the ASMBS commented: “On behalf of our patients, ASMBS is very pleased and gratified that CMS has recognised the true value and compelling need for coverage of this procedure. ASMBS will immediately initiate the formal pathway for coverage with each regional CMS intermediary.”

The Society added that 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”. In addition, they acknowledged that the multi-disciplinary support of the American College of Surgeons, SAGES, The Obesity Society and the American Society of Bariatric Physicians displayed an Obesity Care Coalition in action working for patients’ best welfare.

“We will now go forth to each individual intermediary, and this decision will open the door to widespread coverage based on the strong, available evidence. We are confident coverage will be achieved,” the statement concluded.

The CMS had previously approved national coverage for Roux-en-Y bypass, laparoscopic adjustable gastric banding and biliopancreatic diversion with duodenal switch.

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