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Medicare's Revised Health Insurance Policy For Bariatric Surgery For Diabetes

Armen Hareyan's picture

Medicare wants to limit health insurance coverage for obese patients, but proposes coverage policy for bariatric surgery as diabetes treatment. The Centers for Medicare & Medicaid Services (CMS) announced today its proposal to clarify its policies for Medicare coverage of bariatric surgery as a treatment for beneficiaries with type 2 (or non-insulin-dependent) diabetes.

Following an extensive evidence review, CMS 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 is 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).

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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 careful 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.