CMS clarifies bariatric surgery coverage criteria.(PRACTICE TRENDS)

Medicare will not cover bariatric surgery for beneficiaries who have type 2 diabetes but do not have a body mass index greater than 35 kg/[m.sup.2], according to a proposed decision memo issued last month.

"While recent medical reports claimed that bariatric surgery may be helpful for these patients, [the Centers for Medicare and Medicaid Services] did not find convincing medical evidence that bariatric surgery improved health outcomes for non-morbidly obese individuals," according to a CMS statement.

Dr. Barry Straube, the agency's director of its Office of Clinical Standards and Quality, said, "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." The proposal also clarifies that type 2 diabetes is one of the comorbidities that would be acceptable criteria for surgery.

In 2006, the CMS issued a national coverage decision for bariatric surgery in morbid obesity. That decision said that Medicare would cover only three procedures--open and laparoscopic Roux-en-Y gastric bypass surgery, open and laparoscopic biliopancreatic diversion with duodenal switch, and laparoscopic adjustable gastric banding--for beneficiaries who have a BMI greater than 35, have at least one comorbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity.

At the time, the agency then asked for comments on whether Medicare should cover various gastric and intestinal bypass procedures to improve diabetes status among obese, overweight, and nonverweight ...