National Coverage Analysis (NCA) View Public Comments

Bariatric Surgery for the Treatment of Morbid Obesity

Public Comments

Commenter Comment Information
Wadden, Thomas Title: President
Organization: NAASO - The Obesity Society
Date: 12/23/2005
Comment:

NAASO—The Obesity Society’s Response to the Centers for Medicare and Medicaid Services’ National Coverage Determination for Bariatric Surgery

NAASO – the Obesity Society generally supports the Centers for Medicare and Medicaid Services’ (CMS) National Coverage Determination (NCD) for Bariatric Surgery. This represents an important step that will positively affect the health and well-being of select Medicare recipients who suffer from extreme obesity.

Bariatric surgery clearly is

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Leveille, Genevieve Date: 12/23/2005
Comment:

The surgery should not be excluded from coverage as it is not experimental in nature. Furthermore, this surgery has been shown to relieve many of the morbidity associated with Obesity and provides for reversal of many of these illeness. This is a viable preventation method and not only does it save lifes, it also reduces the medical cost associated with treating many of these co-mordibities that are prevelant among those suffering from this disease.

Maynard, Donald Title: Donald Maynard MD FACS
Organization: Surgical Associates of Metro Atlanta
Date: 12/23/2005
Comment:

Donald Maynard MD Comment on the Biliopancreatic diversion with duodenal switch non-approval by the NCD

Thank you for your efforts to improve the quality of bariatric patient care and access to bariatric surgery through a National Coverage Determination (NCD)

I am concerned that the NCD as it is written specifically excludes the Biliopancreatic diversion with the duodenal switch (BPD/DS, both open and laparoscopic) for Medicare patients and their physicians who want and in

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Schauer, Philip Title: Director of Bariatric Surgery
Organization: Cleveland Clinic
Date: 12/23/2005
Comment:

This new National Coverage Determination (NCD) for bariatric surgery is a major step forward in recognizing obesity as a disease and providing Medicare patients nationwide access to the only treatment for severe obesity that has proven long-term efficacy. Numerous studies have shown that high-volume, high quality centers can deliver outstanding long-term weight loss with gastric bypass and adjustable gastric banding with very low morbidity and mortality (<1%) (1-6).

I, and many other

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Felsher, Joshua Title: Fellow in Advanced Laparoscopy and Bariatrics
Organization: UMass Memorial Health Center
Date: 12/23/2005
Comment:

Bariatric Surgery is Safe and Effective in Patients Over 65

Submitted by the Massachusetts Morbid Obesity Study Group (UMass Memorial Health Center, Brigham & Women's Hospital, Beth Israel Hospital, Massachusetts General Hospital, New England Medical Center)

Background: Recently published reports have brought into question the safety and efficacy of bariatric surgery in the elderly population. As the lifespan of this population continues to increase, the potential health

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Pratt, Gary Title: Chief Executive Officer
Organization: Surgical Review Corporation
Date: 12/23/2005
Comment:

A strong, risk stratified national registry is the cornerstone of a successful center of excellence program. SRC expects to accumulate over 50,000 patients per year in its database. The goals of the ASBS and CMS will be best reached with an accurate and rigorously maintained registry of patients with long-term outcomes.

  • The ASBS BSCOE is administered by an independent, not-for-profit entity guided by industry stakeholders. A major difference between the two programs is that the ASBS BSCOE is managed by an independent corporation with broad stakeholder representation. The ACS initiative is managed solely by surgeons.
  • SRC has the capacity to deliver the data required by CMS to manage its bariatric surgical initiative. SRC has developed the extensive resources required to manage the ASBS BSCOE program including: experienced site inspectors, who are skilled bariatric surgery nurses, to verify data; sophisticated computer hardware protected by a highly secure and redundant data center; and an innovative, completely paperless software system for real-time collection and immediate review of data. Data is collected in full compliance with HIPAA and other privacy requirements under the protection of the peer review process.

    The data elements in SRC’s database registry are based upon those developed by the NIDDK Consortium for the Longitudinal Assessment of Bariatric Surgery (LABS). This registry not only documents obesity but stratifies the co-morbidities and quality of life issues to compare operations and their effects on various populations. A requirement of the ASBS BSCOE program is that each center of excellence must standardize its operations and care pathways. Deviations or changes must be reported. Data is verified by site inspection.

  • SRC data is more current and involves more patients. This can best be illustrated by a recent presentation of the two programs. At a meeting of the Southern Surgical Society on December 6, 2005 (to be published in the May or June issues of the Annals of Surgery), Dr. Mathew M. Hutter of the Massachusetts General Hospital provided the following report of the ACS program from the 12 hospitals participating in the program:

    “From 2000-2003, data from 1,356 gastric bypass procedures was collected. The 30 day mortality rate was zero in the laparoscopic group (n=401) and 0.6% in the open group (n=955), (p=NS). The 30 day complication rate was significantly lower in the laparoscopic group compared to the open group: 7% vs. 14.5% (p<0.0001)…
    Conclusion: Multi-center, prospective, risk adjusted data shows that laparoscopic gastric bypass is safer than open gastric bypass, with respect to 30 day complication rate.”

    Data from the ASBS BSCOE program were also presented in the discussion of the paper. Note that data provided by SRC and shown in Table 1 is current, versus the older 2000-2003 data presented by ACS; that 33,117 patients are included from the initial 106 centers applying for Full Approval versus only 1,356 patients from 12 ACS centers; and that 90 day mortality rates are included from SRC but not available from ACS because NSQIP restricts tracking to 30 days. Finally, the ASBS BSCOE centers have a 30 day mortality of 0.14%, which is considerably lower than the 0.44% reported by the ACS group.

    TABLE 1: Comparison of ASBS AND ACS Data Presented at Southern Surgical Society, December 6, 2005
    ASBS/SRC(2004-5) ACS/NSQIP(2000-3)
    Number of Patients 33,117 1,356
    Number of Hospitals 106 12
    30 day Mortality 0.14% 0.4%
    90 day Mortality 0.9% Not available*

    *NSQIP ends follow-up after 30 days.

  • The ASBS BSCOE program has superior participation. The ASBS BSCOE offers greater access to quality bariatric surgical care through more centers of excellence. Table 2, shown below, offers a comparison of the ASBS/SRC and ACS programs. SRC provides a regular update of the number of participating centers on its website and in newsletters. Information regarding the number of applicants in the ACS program is not maintained on their website and is unknown.

    Table 2: Comparison of Programs
    ASBS/SRC ACS
    Management Industry Stakeholders Surgeons Only
    Relation to Completely Independent Controlled Society
    Hospital Applicants >500 unknown
    # lifetime 125 No requirement
    Required
    # cases/center/year 125 25 (Level II)
    # cases/surgeon/year 50 25 (Level II)
    Surgeon Applicants >900 Unknown
    Full Approval
    Hospital Applicants >130 Unknown
    Full Approval
    Surgeon Applicants >350 Unknown
    Approved Centers >60 Unknown
    Membership University Unknown
    and Private Practice
    Data Collection All patients Aliquot
    Patient Tracking 5+ Years Post-op 30 days postop
    Available Now NSQIP backlog
    Cost $15,000/3 Years >$100,000/yr
    (Level Ia, IIa)

  • The ASBS BSCOE program goes beyond designating centers of excellence. Simply designating centers is not enough. The ASBS BSCOE program coalesces its centers into a research and education consortium that will provide the platform required for cooperative studies, research and continuous quality improvement. The first meeting of this consortium, involving over 100 Centers, will be held early next year to address the following goals: refinement of SRC’s national database registry; the pursuit of investigations into deaths and complications; and the planning of research. We believe this will be a singular opportunity to carry out applied bariatric surgical research in collaboration with industry stakeholders.

    The ASBS, SRC and CMS share common goals to promote bariatric surgical excellence with efficiency, efficacy and safety. Supporting two programs would be detrimental to the industry. For example, centers denied approval by SRC could apply to the ACS program that utilizes lesser standards and receive an “excellence” designation.
    The result would create confusion to the consumer wondering whose care was actually excellent. The ASBS program aims to raise the overall level of care for the morbidly obese, not to lower it by lessening the standards.

    SRC proposes the following to CMS:

    1. CMS selects the ASBS BSCOE program and SRC as its designating organization.

    2. SRC performs site inspections on behalf of CMS.

    3. CMS representatives participate in the direction of SRC’s Consortium for Excellence and assist that body in determining the future direction of bariatric surgery.

    4. CMS has complete access, in accord with HIPAA and peer review guidelines, to SRC’s national database registry containing risk stratified data and be actively involved in the analysis of data and future direction of the national registry.

    In summary, the ASBS BSCOE is the only center of excellence program approved and endorsed by a majority of bariatric surgeons. The program has a broader perspective because it is managed independently and receives its direction from all stakeholders in bariatric surgery, not just surgeons. This program already has tremendous participation from over 500 hospitals and more than 900 surgeons. The cost of the ACS program will present a barrier for participation by most bariatric surgery centers. The ACS NSQIP program does not focus on bariatric surgery, only tracks some of the patients for only 30 days and offers no risk stratification. Finally, the BSCOE Consortium for Excellence concept moves beyond simply designating centers to using the information derived from its program to spearhead continuous quality improvement in bariatric surgery.

    We look forward to working closely with CMS. This can be a valuable partnership from which the consumer becomes the greatest beneficiary.

    Sincerely,

    Walter J. Pories, MD, FACS
    Chairman, Board of Directors

    Harvey J. Sugerman, MD, FACS
    Chairman, Bariatric Surgery Review Committee

    Gary M. Pratt
    Chief Executive Officer

    1. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004 Oct 13;292(14):1724-37. Review. Erratum in: JAMA. 2005 Apr 13;293(14):1728

    2. Buchwald H; Consensus Conference Panel. Bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. J Am Coll Surg. 2005 Apr;200(4):593-604.

    3. Courcoulas A, Schuchert M, Gatti G, Luketich J. The relationship between surgeon and hospital volume to outcome after gastric bypass surgery in Pennsylvania: a 3 year summary. Surgery 2003;134:613-621.

    4. Nguyen,NT, Paya M, Stevens DM, Mavandadi S, Zainabadi K, Wilson SE. The relationship between hospital volume and outcome in bariatric surgery at academic medical centers. Ann Surg 2004; 240: 586-593

    5. Flum DR, Dellinger EP. Impact of gastric bypass operation on survival: a population-based analysis. J Am Coll Surg. 2004 Oct;199(4):543-51

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    On behalf of Surgical Review Corporation (SRC), we support the favorable modifications proposed by the Centers for Medicare and Medicaid Services (CMS) in its National Coverage Determination (NCD) Manual, sections 40.5 and 100.1. This decision will benefit many patients.

    The American Society for Bariatric Surgery (ASBS) realizes the seriousness of surgery for severe obesity and that it is extremely important for surgeons and medical centers to provide quality care. Unlike the past

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  • Giles, David Title: Asst. Professor UConn School of Mediciine
    Organization: UConn SOM, NBGH Clinical Weight Loss Center
    Date: 12/23/2005
    Comment:

    As a general surgeon and critical care surgeon on faculty at the University of Connecticut School of Medicine and the University of Connecticut Health Center, I was directed to become involved with obesity surgery five years ago. Initially skeptical, I was won over to the utility of obesity surgery in the management of morbid obesity by the literature and the testimonials of those involved initially and then by the results that my patients experienced. I agree with CMS that the evidence is

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    Metcalf, Barbara Date: 12/23/2005
    Comment:

    Medicare:It is my sincere hope that someone is actually reading all these comments. I have been involved in bariatric surgery as Clinical Nurse/Program Director, for more than 10 years now. It is my privilege to work with dedicated surgeons in a multidisciplinary program. I follow surgical weight loss patients that go out over 20 years. I also follow our Open postop Duodenal Switch patients, numbering more than 400, going out 12 years. Our Lap DS patients now number 1030, with no

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    Murr, Michel Title: Associate Professor of Surgery
    Organization: University of South Florida
    Date: 12/23/2005
    Comment:

    We have done a recent study that evaluated intermediate outcomes of bariatric surgery in 25 patients who underwent bariatric surgery at two university-affiliated programs in Florida. Not only weight loss in these patients was similar to that achieved in younger patients but there was significant resolution of obesity-related medical comorbidities (diabetes 100% resolution; sleep apnea 77% resolution; and hypertension 67% resolution …etc) and a significant reduction of medication use

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    Morton, John Title: Director of Clinical Research
    Organization: Bariatric Partners
    Date: 12/23/2005
    Comment:

    Bariatric Partners, Inc
    7401 Carmel Executive Park
    Suite 200
    Charlotte, NC 28226

    December 23, 2005

    CMSComments re National Coverage Decision – Obesity Surgery

    Please note that an attachment has been sent to CAGinquiries@cms.hhs.gov which includes citations not able to be copied in this document.

    This comment is on behalf of Bariatric Partners, Incorporated. Bariatric Partners, in partnership with physicians, develops and manages weight loss centers

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    Jan, Jay Title: Bariatric Surgeon
    Organization: Oregon Weight Loss Surgery, LLC
    Date: 12/23/2005
    Comment:

    We would like to submit several comments to the Center for Medicare and Medicaid Services (CMS) on the proposed coverage decision for bariatric surgery. Our practice consists of three fellowship-trained surgeons performing bariatric surgery at Legacy Hospitals in Portland, Oregon, with Laparoscopic Roux-en-Y Gastric Bypass, Laparoscopic Adjustable Gastric Banding and Laparoscopic Biliopancreatic Diversion being the most commonly performed procedures in our practice.

    Overall, we

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    Zimmerman, Kathryn Date: 12/23/2005
    Comment:

    It is a dreadful mistake to withold duodenal switch from the population under 65. Long term success in weight loss maintenance is better with duodenal switch than with RNY, with better quality of life and the ability to eat fairly normally without dumping or vomiting. The Lap Band ends up being more costly because of adjustments and causes problems with erosion, and also results in less weight loss.

    It is a dreadful mistake to withhold weight loss surgery from the over 65

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    parker, faith Date: 12/23/2005
    Comment:
    this surgery is life saving and MUST be kept! Please do the right thing and help make people healthy!!!!!!!!!
    Shabi, Rick Title: President
    Organization: NHS Bariatric
    Date: 12/23/2005
    Comment:

    I have worked in the field of bariatric surgery for the past ten years. In conjunction with experienced and dedicated bariatric surgeons and hospitals, we developed bariatric surgery centers in many Midwest and Southeast metropolitan areas, including Chicago, Cleveland, Indianapolis, Louisville KY, and Nashville TN. These centers continue to operate today and are standard-bearers in their area for quality care and commmitment to patient success for a lifetime after surgery.

    In recent

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    smith, EILEEN Date: 12/23/2005
    Comment:

    This surgery is needed for those who are disabled or who have issues that make weight loss diffcult. Taking this surgery away from Medicare patients could shorten their lives and make them sicker.

    Furco, Linda Date: 12/23/2005
    Comment:

    What happens to those with a Nissen fundiplication- RNY and Lapband are not going to be options for them. They will need a biliopancreatic diversion/duodenal switch, BPD/DS (duodenal switch)as an option to benefit from surgery. The BPD/DS has been long proven to be the most effective surgery in regards to % of excess weight lost and long term success. Dr. Hess, Dr. Husted, Dr. Spaw, Dr. Smith, Dr. Maynard, Dr. Gonzales, Dr. Rabkin and many other Doctors across the county have 1,000 s of

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    laird, pat Date: 12/23/2005
    Comment:

    Why would you want to exclude the WLS with the best results? Read the studies, BPD/DS allows the least regain and the highest percentage of excess weight lost. If you're going to use my tax dollars to pay for it; I'd rather buy the one that works!

    Becker, Barbara Date: 12/23/2005
    Comment:

    The Gastric Reduction with a Duodenal Switch is a life-saving operation for people with Morbid and Super Morbid Obesity. The cost savings for the future due to the elimination of co-morbidities are well documented in research. It is very important that this surgery remain as an approved treatment for Morbid and Super Morbid Obese people.

    Hinnenberg, Renie Title: CFO
    Organization: Spellworks, Inc
    Date: 12/22/2005
    Comment:

    The BPD with duodenal switch is the best surgery around for long term results, to dis allow a superior treatment for obesity with out true cause is to limit the chance of success.

    Wolfe, Bruce Title: Bruce Wolfe, MD, Professor of Surgery
    Organization: Oregon Health & Science University - Division of General Surgery
    Date: 12/22/2005
    Comment:

    CMS is to be commended for the extraordinary effort made to evaluate the appropriate role of bariatric surgery as treatment for morbid obesity in the Medicare population. We concur with the conclusion that gastric bypass and laparascopic adjustable banding (LAGB) are indicated as primary intervention for Medicare beneficiaries with comorbidity and associated with morbid obesity and associated comorbidity. The issue of Medicare beneficiaries greater than 65 years of age requires additional

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    Wilson, Richard Title: Chief Medical Officer
    Organization: EnteroMedics Inc.
    Date: 12/22/2005
    Comment:

    Thank you for the opportunity to provide comments on the proposed decision for Bariatric Surgery for the Treatment of Morbid Obesity (CAG-00250R). I am the Chief Medical Officer of EnteroMedics Inc., a company dedicated to developing novel medical devices to treat obesity. Our purpose with this communication is to express our support for the thoughtful and thorough approach that you are taking with this proposal. We all share the challenge of addressing the individual and public health

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    Kamelgard, Joseph Title: MD, FACS
    Organization: Lighter for Life
    Date: 12/22/2005
    Comment:

    I would like to commend the Centers for Medicare and Medicaid Services (CMS) for their thoughtfulness and efforts in attempting to improve healthcare access in the United States by addressing the weight loss surgery options for morbidly obese Americans through its recent National Coverage Decision (NCD). Having read the decision summary, I recognize that the decision making process was not an easy one and therefore appreciate this opportunity to make a public comment. I would specifically

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    Bauman, Roc Organization: Carolina Weight Loss Surgery
    Date: 12/22/2005
    Comment:

    Dear Doctor Phurrough: As a bariatric surgeon in NC I have performed 1000 bariatric procedures over the last 5 years and have had the priviledge of observing the profound improvements in comorbidities and lifestyle that resulted from these surgeries. Some of the most dramatic improvements have been in the over 60 age group, including a number of patients over 65. To limit their access based on age alone is not only unjust but unrealistic as our average lifespan continues to lengthen. These

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    Sox, Harold Title: Editor
    Organization: Annals of Internal Medicine
    Date: 12/22/2005
    Comment:
    I favor providing coverage for bariatric surgery only for those willing to enter a randomized trial of surgery. We don't know the clinical effects of this surgery in the Medicare age group. Providing an intervention only for those who agree to participate in a trial has ample precedent. Trials of unapproved interventions (e.g., a new drug for metastatic cancer) are the only way that a person can get a chance to receive the intervention.

    Caya, David Title: Doctor of Chiropractic
    Date: 12/22/2005
    Comment:

    Regarding the question of Medicare funding forbariatric procedures, published research hasrepeatedly shown that there is great benefit forthose individuals in need of this service. Thedecision as to whether or not a surgical procedureis well advised for a particular individual shouldbe left up to the individual and his or hersurgeon. The question of Medicare funding islarger than this. Many private insurance carriers’official medical policies are influenced by, ifnot based on, Medicare

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    Shaikh-Herbst, Sufia Date: 12/22/2005
    Comment:

    The DS is the best hope that an obese person can be offered. It is far superior to the RNY due to the normal stomach (pyloric valve) being kept intact. It is all but a cure for diabetes and other weight related comorbidities. Please don't take away this hope for a normal life because of money. It means the difference between life and death for so many. All of the results of long term weight loss prove all of this. Thank you!

    Kadow, Mari Title: Clinical Dietitian/WIC Coordinator
    Organization: St. Joseph's Area Health Services
    Date: 12/22/2005
    Comment:

    Thank you for your efforts to improve access to weight-loss surgery through a National Coverage Decision. As a Registered Dietitian dealing with bariatric patients I see how bariatric surgery can improve patient’s quality of life on a daily basis.

    The bariatric program in our facility has provided bariatric surgery to over 1300 patients since 2001. We collect data confidentially on all of our bariatric surgery patients. Recently we reviewed our data for outcomes specific to

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    King, Cathy Title: Surgical Weight Loss Program Coordinator
    Organization: St. Joseph Regional Health Center
    Date: 12/22/2005
    Comment:

    As Coordinator of the Surgical Weight Loss Program at St. Joseph Regional Health Center in Bryan, Texas, I am submitting a comment regarding CAG-00250R: the proposed modification to the NCD manual sections on bariatric surgery for the treatment of morbid obesity.

    Your review of current literature repeatedly notes that there is inadequate research available on the results of bariatric surgery in the elderly, yet you propose to discontinue coverage for this population. In this era

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    Taylor, RN, BSN, Sylvia Title: Coordinator of Bariatric Services
    Organization: Boone Hospital Center
    Date: 12/22/2005
    Comment:
    I believe that Medicare should provide coverage to those that are suffering from obesity. I support Medicare including coverage for Gastric Banding using the LAP-BAND system. It would be very beneficial to those that have extreme medical conditions and for those that may not be candidates for Gastric Bypass surgery. The LAP-BAND has been proven to be a much safer operation with a safer weight loss and less complications. Thank you for your consideration.
    B, Patti Date: 12/22/2005
    Comment:

    Please do not take obese peoples chances for a normanl, health life away. Obesity is the larges growing disease in the US. You would not consider not paying for someone with Aids. Please do not discriminate, I would expect more of you.

    Dunham, Kathleen Title: Senior Reimbursement Manager
    Organization: Medtronic, Inc.
    Date: 12/22/2005
    Comment:

    Medtronic, Inc. welcomes the opportunity to respond to the Centers for Medicare & Medicaid Services’ (CMS’) request for public comment on the National Coverage Analysis (NCA) for Bariatric Surgery for the Treatment of Morbid Obesity. Medtronic is the world’s leading medical technology company, providing lifelong solutions for individuals with chronic diseases and enhancing the lives of Medicare beneficiaries.

    In reviewing the proposed NCA, Medtronic was pleased

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    Brengman, Matthew Title: Bariatric Surgeon
    Organization: Richmond Surgical Group
    Date: 12/22/2005
    Comment:

    To whom it may concern,

    We are very concerned and disappointed that CMS would consider limiting or eliminating the bariatric surgery benefit for patients over sixty-five. I understand the concerns regarding safety, efficacy and cost. I will elaborate on our recent experience with this population in an effort expel some of these concerns.

    Our group began placing Laparoscopic Adjustable Gastric Bands in September of 2004. To Date we have placed 15 of our 110 Lap-Bands in patients

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    Nicastro, Jeffrey Title: Director of Bariatric Surgery
    Organization: Staten Island University Hospital Center for Surgical Treatment of Obesity
    Date: 12/22/2005
    Comment:

    As the director of a bariatric center that recently received full approval from the surgical review corporation/ ASBS as a center of excellence in bariatric surgery I believe that I have reasonable insight and first-hand knowledge on this topic.

    The 1991 Consensus statement from the NIH together with the 1998 "Evidence Document" on Overweight and Obesity in the United States, form the basis for the clear justification of a surgical approach to obesity.

    The rise in

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    Furco, Tabetha Date: 12/22/2005
    Comment:

    I am curious as to know why something that has been proven to help people is going to be unavailable. Is it not true that everyone deserves access to medical procedures? Why would the government choose to deny people the right to life, liberty, and the pursuit of happiness by denying this procedure? People could lose their lives by not having this available, they risk their health not ever being better, and happiness comes with self content, which the decision to remove this surgery from

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    Nguyen, Ninh Title: Associate Professor of Surgery
    Organization: University of California Irvine Medical Center
    Date: 12/22/2005
    Comment:

    I suggests that your organization reconsider the decision for denial of coverage for the two-stage procedure. Despite my extensive experience in laparoscopic bariatric surgery, there are a group of patient who I would considered as high- surgical risks and would benefit from this approach. For example, we have found that large males with central obesity are prime candidate for the two-stage operation as these patients have been shown to have higher morbidity and mortality. A major technical

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    Randle, Stuart Title: President and Chief Executive Officer
    Organization: GI Dynamics, Inc.
    Date: 12/22/2005
    Comment:

    GI Dynamics, a privately held, venture-backed company that is developing innovative products for the treatment of obesity and its complications, welcomes the opportunity to provide comments on the proposed Medicare coverage policy for Bariatric Surgery for Treatment of Morbid Obesity.

    Morbid obesity is an important and often medically intractable health problem, one for which current therapeutic options are clearly less than satisfactory. Many individuals for whom obesity

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    Baker, MD, FACS, John Wilder Date: 12/21/2005
    Comment:

    Sirs:

    I thank you for the National Coverage Decision for bariatric surgery for Medicare recipients. In 2001, fourteen percent of the Medicare beneficiaries were younger than 65. The baby boomers are approaching the elgible age quickly. Coverage should be considered for the group 65 and older as well. The Medicare Payment Advisory committee report to Congress March, 2005 outlines the increased cost our society faces due to obesity.

    From the Report" Lifestyle and health

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    Owens, Sylvia Date: 12/21/2005
    Comment:

    Thank you for for efforts to improve access to weight-loss surgery. I am concerned that persons over 65 are excluded. While I understand that they may be of higher risk, I know of several persons who were over 65 who were very successful.

    I urge you to continue your efforts to expand treatment for obesity and ask you to look again at excluding someone simply because they are over 65.

    Thank you.

    Ramos, Monica Date: 12/21/2005
    Comment:

    I think it is really dumb that the government would rather pay for all of the rpescriptions and treatments that co-morbidities cause, then pay for a surgery that eliminates a majority of all of that. Age should not be a contributing factor to this decision...

    Smith, Daniel Title: Chief of Surgery
    Organization: Dakota Clinic - Park Rapids, St. Joseph's Area Health Services
    Date: 12/21/2005
    Comment:

    This letter is in regard to the proposed Medicare rule regarding denial of payment for bariatric surgical procedures in patients 65 years and older.

    Within our program, we have performed over 1300 Roux-en-Y gastric bypasses in the last five years. Among that group, there have been 18 patients in the age 65-74 range. The analysis of this patient group shows a low rate of complications and no mortalities. The excess of body weight loss averaged 73%. Among this older population reversal of

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    Sauter, Benjamin Date: 12/21/2005
    Comment:

    Taking the option for people to improve their lives is wrong. People dont have this surgery for vanity, they have it so that they are able to live their life and contribute to society.

    Shame on the people who want to take that away from people.

    Cempa, Stella Title: Student Account Officer
    Organization: FMU
    Date: 12/21/2005
    Comment:

    Age should not be a factor in the determination of Bariatric Surgey. Many people at the age of 65 or older are in need of the the surgery. As long as the person is able to with stand the surgery I think he or she should be able to have it. I also think the insurance company's should be made to pay for the prcedure. Morbid Obesity is a disease and should be treated as such.

    anthone, gary Title: Director of Bariatric Surgery, Physicians Clinic
    Organization: Nebraska Methodist Health System
    Date: 12/21/2005
    Comment:

    I have written and presented numerous articles demonstrating the safety and efficacy of the Duodenal Switch (DS) procedure as a treatment option for patients with morbid obesity. Having performed this procedure (DS) over 1400 times with a mortality rate below 1% and a morbidity rate lower than reported for Roux en-Y Gastric Bypass I am wondering how CMS can state the data is "inadequate" to support its use. I was also the first surgeon to report on the use of the "sleeve gastrectomy" as a

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    Sauser, Robert Date: 12/21/2005
    Comment:

    Thank you for your efforts to improve access to weight-loss surgery through a National Coverage Decision. In Northern Minnesota, I see daily how bariatric surgery can improve patient’s quality of life.

    Our program has provided bariatric surgery to over 1300 patients since 2001. We collect data confidentially on all of our bariatric surgery patients. Recently we reviewed our data for outcomes specific to our patients 65 years of age and older. I was not surprised by our

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    Blackstone,MD,FACS, Robin Title: Medical Director
    Organization: Scottsdale Bariatric Center
    Date: 12/21/2005
    Comment:

    I appreciate the careful and deliberate way that Medicare has approached this difficult topic. I completely agree with their coverage decision regarding the treatment of Medicare patients for the indication of Morbid Obesity under the age of 65 but would like to provide additional evidence on the group of patients 65 and over.

    Scottsdale Bariatric Center represents a group of three surgeons, two internal medicine physicians practicing as Bariatricians, two psychologists with a

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    DeMaria, Eric Title: Vice Chair and Director, Bariatric Surgery
    Organization: Duke University
    Date: 12/21/2005
    Comment:

    While I applaud the medicare coverage decision in so many ways, I must speak out against two exclusions that have been included in the final document with which I strongly disagree.
    1. Bariatric surgery in patients over the age of 65- Age discrimination in this field is an unfounded concept based primarily on studies from large administrative databases (such as Flum, et al. JAMA 2005) which provide insufficient clinical data to characterize the patient population other than ‘age’.

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    Bryan, Martha Date: 12/21/2005
    Comment:

    To The Centers for Medicare and Medicaid Services:

    I am writing this comment in response to The Centers for Medicare and Medicaid Services’ proposal of a coverage decision that would negatively impact potential weight-loss surgery patients. The decision, I understand, would eliminate Medicare and Medicaid coverage entirely for the Duodenal Switch procedure, and also eliminate coverage of weight loss surgery for people over the age of 65, among other things. I am extremely concerned

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    Kennedy, Scott Date: 12/20/2005
    Comment:

    Please do not remove coverage for the duodenal switch. For some people, it is the only relevant option to enact critically needed weight loss.

    Kavulak, Elaine Date: 12/20/2005
    Comment:

    I am here to support the Duodenal Switch surgery for people who are morbidly obesity(BMI above 40) and super morbidly obese (BMI 50 and above). I also support this for people who are over the age of 65 if the physician determines that the duodenal Switch is the appropriate surgery.

    The Duodenal Switch is the newest developing generation of weight loss surgery.

    It seems to me like denying people on medicare access to this surgery is a form of discrimination to those who are

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    Ver Steeg, Kyle Title: Bariatric Surgeon
    Organization: Iowa Bariatrics
    Date: 12/20/2005
    Comment:

    I have done 5-patients 65-years and older without significant morbidity or mortality [gastric bypass]. All have been extremely pleased with the effect upon their quality of life. I agree with Walt Pories that the best way to gather more data is to require registration of these patients in the SRC registry or the International Bariatric Surgery Registry of Dr. Ed Mason's.

    Sincerely,
    Kyle Ver Steeg, MD

    Kazon, peter Title: Attorney
    Organization: Alston and Bird
    Date: 12/20/2005
    Comment:

    Comments of Inamed Corporation to CMS on Proposed Bariatric Surgery NCD

    Inamed Corporation (“Inamed”) would like to thank the CMS staff for their diligent and hard work in developing this Proposed National Coverage Determination on Bariatric Surgery. This is a significant step forward in creating a homogeneous policy for all Medicare Beneficiaries. We would like to offer the following comments relative to the Proposed NCD.

    1. Inamed is opposed to limiting access to bariatric

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    Sandoval, Carolyn Date: 12/20/2005
    Comment:

    I don't think it is right for Medicare to stop paying for Barriatric surgery. It has and will continue to save a lot of peoples life.

    wolff, robin Date: 12/20/2005
    Comment:

    Bariatric Surgery is so important to our future. It has literally changed the lives of millions of obese people. Whether someone is 45 or 66 we all have our lives to live and if we are sick "morbid obesity" we deserve the same chance someone has that has an medical problem. We are all living longer and when we are sick we should be able to rely on our health care system to get the help we need. Please reconsider helping people older than 65 in obtaining the medical attention they need for

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    Rawls, NaDine Date: 12/20/2005
    Comment:

    Dear Decision Maker
    To limit surgery for those who is Morbidly obese regardless of their age is sending a message to people that their health is less important than the amount of money it takes. Persons who are morbidly obese are probably taking a large number of medications. I have seen persons who were diabetics or have high blood pressure, have the surgery and were off of these medications in a matter of months thats saves Medicare/Medicaid thousands of dollars alone. If Medicare

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    Senescu, Randee Date: 12/20/2005
    Comment:

    An absolute lifesaver!

    Garver, Jim Title: Director of Reimbursement
    Organization: Inamed Corporation
    Date: 12/20/2005
    Comment:

    Comments to CMS on Proposed Bariatric Surgery NCD

    Inamed Corporation (“Inamed”) would like to thank the CMS staff for their diligent and hard work in developing this Proposed National Coverage Determination on Bariatric Surgery. This is a significant step forward in creating a homogeneous policy for all Medicare Beneficiaries. We would like to offer the following comments relative to the Proposed NCD.

    1. Inamed is opposed to limiting access to bariatric surgery solely to

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    Bariatric, US Title: Bariatric Surgeon
    Organization: US Bariatric
    Date: 12/20/2005
    Comment:

    Upon the request of the American Society for Bariatric Surgery (ASBS), the Center for Medicare and Medicaid Services (CMS) recently released a National Coverage Determination (NCD) for the provision of bariatric surgery for Medicare and Medicaid patients.

    US Bariatric (USB) agrees with CMS that Medicare patients should undergo their surgery at high quality surgical centers. These Institutions would be Centers where: 1) 125 or more procedures are performed annually, 2) each surgeon

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    Eads, Lisa Date: 12/20/2005
    Comment:

    Bariatric surgery to treat morbid obesity is the only realistic option for the morbidly obese. Denying this coverage only insures the patient's death. Weight loss without surgical intervention has a less than 1% success rate in the long run. Less than 1% of people who diet to lose weight, keep the weight off for 3 years. I think this statistic speaks for itself. Without surgical intervention, maintaining a lower bmi (body mass index) is hopeless.

    Denman, William Title: Medical Director
    Organization: Tyco Healthcare
    Date: 12/20/2005
    Comment:

    We commend CMS on reaching a national coverage decision regarding bariatric surgical coverage for its beneficiaries. As a long time supplier of instrumentation to the bariatric surgery community, we agree with the decision to provide coverage for open and laparoscopic Roux-en-Y gastric bypass (RYGBP) and laparoscopic adjustable gastric banding (LAGB) for Medicare beneficiaries who are under 65 years of age, have a body-mass index (BMI) > 35, have at least one co-morbidity related to

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    Colias, Donna Date: 12/20/2005
    Comment:

    Stop penalizing the low income individuals needing the appropriate health benifits. This surgery with all the variations has proven to help the morbid obese, and I believe that the doctor making the decision to do the surgeries should be the one in control of what is needed.

    Senior, Holly Date: 12/20/2005
    Comment:

    Denying coverage for this life-changing surgery would be a travisty! Sometimes conventional dieting methods do not help!

    Suggs, William Title: Medical Director Bariatric Surgery
    Organization: The Surgical Weight Loss Center
    Date: 12/20/2005
    Comment:

    CMS should continue to focus on outcomes following bariatric surgery, including taking into account high-risk patients which will skew the outcomes, as well as considering that many "complications" are actually secondary to their extensive medical comorbidities, not the surgery itself.

    Small volume centers, such as those in rural America, should be allowed to continue offering bariatric surgery for 2 very important reasons:

    1. patients who have to travel long distances

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    Perez, Jessica Date: 12/20/2005
    Comment:

    I would like to ask that you seriously consider that you not exclude people over 65 from having weight loss surgery. For some this would be the only "tool" left to them. Please reconsider. Thank you for listening. Jessica Perez

    Tullo, Pam Date: 12/20/2005
    Comment:

    Weight loss surgery is not a cosmetic procedure. It is a treatment for severe obesity. The procedure itself, as well as the lifestyle adjustments that must be made afterward, are not easy and should not be undertaken lightly. But for someone who has been severely obese and unable to lose weight by non-surgical means, it is a life-saving procedure. It can also be a money-saving procedure, as many patients are able to stop taking medications or seeing specialists for conditions such as

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    Downey, Morgan Title: Executive Director/CEO
    Organization: American Obesity Assn
    Date: 12/20/2005
    Comment:
    The American Obesity Association (AOA) is pleased to comment on the proposed National Coverage Decision on Bariatric Surgery for Morbid Obesity. We strongly agree with the decision to expand coverage for the non-elderly Medicare beneficiaries who are disabled. We also strongly support coverage of services when provided in a Center of Excellence established by the American Society for Bariatric Surgery and the Surgical Review Corporation (hereinafter ASBS/SCR). However, we strongly object

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    Jenkins, Dale Title: CEO
    Organization: Medical Mutual Insurance Company of NC
    Date: 12/20/2005
    Comment:

    My name is Dale Jenkins and I am the CEO of Medical Mutual Insurance Company of North Carolina. We provide professional liability insurance for over 8500 physicians in NC, VA and GA. At the request of Dr. Walter Pories, I am also a member of the Board of Directors of SRC.

    I believe that bariatric surgery can be a true life changing and life saving event for many people. The effectiveness of this surgery is well documented. However, we all know that not every obese individual is an

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    Williams Sr., Tom Title: Mr.
    Date: 12/20/2005
    Comment:

    After reading many negative comments directed at obese individuals, or at Medicare for considering W.L.S. I feel something needs to be stated. Most individuals seeking W.L.S. have spent lifetimes trapped in tortured bodies educating themselves in weight loss. Most have tried multiple avenues of weight loss and showed more self discipline than many healthy weight people. Our problem is we have been unsuccessful in overcoming our affliction. W.L.S. is in most cases a life saving last

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    WILLIAMS, D Date: 12/20/2005
    Comment:

    Please do not deny our seniors the opportunity to take advantage of this life saving procedure. They are the one's resonsible for who we are today.

    A, Bobbie Date: 12/19/2005
    Comment:

    The adjustable gastric band should be fully covered by Medicare. It is so hard for an older person to lose weight on their own and the band is a great tool to help them achieve a healthy weight. The cost of healthcare for the obese in the elderly is too much as things are today. With minimal risk surgery and resulting weightloss, the long-term costs would be greatly reduced.

    Hansen, PATRICIA Date: 12/19/2005
    Comment:

    Please do not eliminate this coverage for Medicare patients. As many others have posted this procedure is not only life changing but life SAVING. Add to that it dratically improved quality of life and often eliminates all or most co-morbidities.
    Thank You
    Patt Hansen

    Cain, Deana Date: 12/19/2005
    Comment:

    Im not sure who made this decision........it's bad enough to survive being normal, with health issues and being over weight many people could not get a chance to be HEALTHY or HAPPY without insurances. Why would you do this? This make no sense at all your telling us were a obese country and you want to take that chance away. Many of us would never get a chance of being NORMAL, that may not sound much to you and the government but to us little people....means EVERYHTING!!! Please re-think

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    Brolin, MD, Robert E. Title: President
    Organization: NJ Bariatrics, PC
    Date: 12/19/2005
    Comment:

    MEDICARE POLICY OBESITY

    I am taking this opportunity to comment on the National Coverage Decision (NCD) on bariatric surgery for Medicare patients. Although I respect Medicare for confronting this difficult issue, I was particularly disturbed by Medicare’s denial of bariatric surgery for “retirees,” those patients age 65 and/or over. As a bariatric surgeon I remain cynical regarding Medicare’s motivations and those of other third party payers regarding their willingness to

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    Alder, Henry Title: Director, Reimbursement & Healthcare Economics
    Organization: Ethicon Endo-Surgery, Inc.
    Date: 12/19/2005
    Comment:

    On behalf of Ethicon Endo-Surgery, Inc., a Johnson & Johnson company, we wish to submit our comments to the Center for Medicare and Medicaid Services (CMS) on the proposed coverage decision for bariatric surgery for morbid obesity that was issued on Wednesday, November 23, 2005. Ethicon Endo-Surgery, Inc. manufactures and distributes minimally invasive surgery products used for open and laparoscopic gastric bypass. Overall we support Medicare’s assessment of bariatric surgery and

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    Weyman Kegg, Marilyn Date: 12/19/2005
    Comment:

    Why is age the criteria?

    The suitability of a procedure for an individual should be determined by a certified physician or a group of physicians after taking all the facts and data about each patient into consideration.

    Age is not the proper factor for this determination. The condition of the patient surely must be the only real consideration

    Why would a patient be less fit for this surgery one day after their 65th birthday than they were the day before

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    Smiertka, Jackie Title: R.N. Program Coordinator/ Ed/Pub Beyond Change
    Organization: Bloomfield Bariatrics, beyondchange-obesity.com
    Date: 12/19/2005
    Comment:

    Since 1991 I have worked with the Duodenal Switch procedure. Previously working with gastric bypass patients and VBG's I was very leary of this 'new' procedure. What I soon realized was how wonderful the DS was for the patient. It did then and continues to this day to provide a normal quality of life for this particular group who have not only lost weight and kept it off but have been able to enjoy life without severe restriction and without severe deficiencies. We have had the pleasure

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    Oakley, W. C. Organization: Bariatric Surgery Center of Idaho
    Date: 12/19/2005
    Comment:

    Medicare should not exclude BPD/DS for the treatment of morbid obesity since it has been done in hundreds of patients over more than a decade with good results. Many of us who are experts believe it is, in fact, the procedure of choice for the "super obese"-those who are most in need of surgical weight loss for life-saving reasons since it is both safer to do in these large patients, and more effective. No operation is perfect, but do not take away the safest and best option for these,

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    Walters, Leah Title: Bariatric Coordinator
    Organization: St Joseph's Area Health Servicers
    Date: 12/19/2005
    Comment:

    Thank you for your efforts to improve access to weight-loss surgery through a National Coverage Decision. As coordinator of a comprehensive weight management program at a community hospital in Northern Minnesota, I see daily how bariatric surgery can improve patient’s quality of life.

    Our program has provided bariatric surgery to over 1300 patients since 2001. We collect data confidentially on all of our bariatric surgery patients. Recently we reviewed our data for outcomes

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    randall, sheldon Title: Director of the Obesity Program
    Organization: Hallmark Health- Lawrence Memorial Campus
    Date: 12/19/2005
    Comment:

    Dear Sirs,
    I was disheartened by your decision re 65 yrs and older patients not being approved for gastric bypass surgery. I have been performing open gastric bypasses for 20 yrs now. I ahve two practices—one at Mass General Hospital and the second in a community hospital just north of Boston. It is here that over the past 6 years I have operated on over 120 patients that were 65 yrs of age or older and have not had one death. the morbidity rate remains similar the the younger

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    Shikora, Scott Title: Chief, Bariatric Surgery
    Organization: Tufts-New England Medical Center
    Date: 12/19/2005
    Comment:

    Dear Sir,

    I too, wish to weigh in on this decision. I am a bariatric surgeon who has performed over 1500 gastric bypasses in my 14 year career. Included in those cases were 25 patients 65 years and older (65-77). I analyzed their results and found that the complication rates, mortality, weight loss, and outcomes were no different for the older patients as compared to younger patients.

    There are currently no restrictions for age when it applies to cancer, open heart, or

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    McCauley, Dorothy Title: RN CDE
    Date: 12/19/2005
    Comment:

    In my poinion as a health care proffessional the Gatric Banding prceedure should be covered,and NOT the Gartric BYPASS, this proceedure id a lot less invasive as bypass and requires less time in the hospital and infact can be performed as an outpt proceedure.The recovery time is cut by 70% and the pt is able to go back to work within 5-6days,The effect on people with Diabetes has been extreemly helpfulin terms of the weight loss,mand in the long run costs a lot less than treating the long

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    DORNBACH, Shelly Date: 12/19/2005
    Comment:

    To whom It May Concern,

    If infact the Weight Loss Surgery is excluded their will be much higher medical cost for medicare in the future because of diabetes, heart attack, and all the other alements that go along with being obese. Socail Security will be pushed to more of a limit, with the amount of people that will be filing disablity in the future for the cause of morbid obesity. In the long run the exclusion of Weightloss Surgery will bare a much higher cost in the future than the

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    Davis, Pamela Title: Surgical Weight Loss Program Coordinator
    Date: 12/19/2005
    Comment:

    I am the program coordinator for a Surgical Weight Loss Center in TN. In 1.5 years, we have performed 65 cases, which includes 9 (nine) Medicare patients. Two of our Medicare patients were >age 65 (ages 66 & 72) with severe diabetes (A1Cs were 13 & 11.2 respectively). Both patients had successful laparoscopic RNY gastric bypass, both were off insulin by discharge from the hospital. The 66 year old stopped all diabetic medications at six weeks postop., the 72 year old stopped all diabetic

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    Broomhall, Angeline Date: 12/19/2005
    Comment:

    This is a hot topic. I implore you to expand on coverage for Obesity treatments and not exclude it. Obesity is killing people in this and other countries at alarming rates. While it may be true that there is no conclusive evidence that certain procedures are effective, that is only because this area is so new. If we close the door now, we will doom ourselves to generations dying earlier and earlier. Thank you for your consideration and understanding.

    Stack, Kerry Date: 12/19/2005
    Comment:

    I think that if the patient would benefit from the surgery by ridding themselves of any one of the co-morbidities, they should be allowed to have the surgery and have it covered by medicare. I think that would bring overall costs to the medicare program down.

    Cover this wonderful, lifechanging surgery for all who need it!

    Nadglowski, Joseph Title: President/CEO
    Organization: Obesity Action Coalition
    Date: 12/19/2005
    Comment:

    On behalf of the Obesity Action Coalition (OAC), I would like to take this opportunity to thank the Centers for Medicare and Medicaid Services (CMS) for their efforts in reviewing the scientific-evidence validating bariatric surgery as an effective treatment of morbid obesity and proposing rules that would expand access to bariatric surgery. The OAC strongly supports the coverage of weight-loss surgery as studies show the surgical treatment of morbid obesity decreases mortality, improves

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    gafa, sharon Date: 12/19/2005
    Comment:
    this surgery should be FREE, there are so many people who need this operation and cannot afford it
    godmintz, katie Date: 12/18/2005
    Comment:

    Lap Band Surgery should be allowed till the age of at least 75. It's a simple procedure,not bypass and would cost the govt.little compared to the cost savings from obese related diseases.

    Norris, Margaret Title: Psychologist
    Organization: Private Practice
    Date: 12/18/2005
    Comment:

    As a member of the bariatric surgery team at St. Joseph’s Hospital in Bryan Texas, I am submitting a comment regarding CAG-00250R: the proposed modification to the NCD manual sections on bariatric surgery for the treatment of morbid obesity. The specific concern is with the statement “Each institution will have staff and readily available consultations in cardiology, pulmonology, rehabilitation, and psychiatry who have prior experiences with bariatric surgery patients.”

    The

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    Hess M.D., Douglas S. Title: surgeon, MD
    Organization: ASBS
    Date: 12/18/2005
    Comment:

    December 18, 2005

    Morbid and super morbid obesity is a seriousdisease and very difficult to treat. Presentlyonly surgery has a significant long termsatisfactory result on this medical condition. There are several types of surgical procedures andall have some complications. The morbid obesepatient has serious comorbidities, such asdiabetes, hypertension, arthritis, cardiacdiseases as well as difficulty in their normaldaily activities.

    I have performed bariatric surgery for 26years.

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    Hill, Shelia Date: 12/18/2005
    Comment:

    In my opinion this surgery should NOT be discontinued. It gives people the chance at a better life. Anyone that has never been obese does not know and has no conception what it is like. Not everyone can just bang lose weight or there would be no obesity in this day and age. Why should the age be an issue? Just because a person is over the age of 65 does not make them any less of a person that needs help. When in fact it would help in the length of their life along with the quality of life.

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    Widemark, Sue Date: 12/18/2005
    Comment:

    Good idea to restrict medicare coverage for bariatric surgery for those over 65. I think it should be restricted for those over 50... as the mortality rate from this surgery for older people by some studies is 40 percent. And especially since it has been shown that fat people who exercise are at no higher risk for morbidity than normal weight people who exercise.

    A recent study found that for people of age 65 to lose weight even by healthier ways than bariatric surgery, is so

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    Barabe, Janice Date: 12/18/2005
    Comment:

    You cannot afford to stop Weight Loss Surgery. Have you not read about all the benefits for a persons health AFTER THE SURGERY? You will be paying much more for medications,weight related surgeries, diabities, etc. Penny wise and a dollar foolish!!!

    Barber, elaine Title: LICSW
    Date: 12/17/2005
    Comment:

    [PHI Redacted] I hope that other alternatives would be covered prior to surgery. Cognitive-behavioral groups with peers, nutrional counseling and individual psychological support are effective and helpful.

    Fermelia, Richard Title: Bariatric Director
    Organization: American Society for Bariatric Surgeons
    Date: 12/17/2005
    Comment:

    To deny bariatric surgery to severely obese patients simply because they are over 65 is NOT appropriate. We have a number of patients that have exceptionally well and we have not had complications in patients over 65. Bariatric surgeons and programs(Ones that you identify as appropriate via a centers of excellence)have the good judgement to consider the whole patient including the impact of comorbidities on morbidity and mortality. We have refused some older patients on that basis. I would

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    Gordon, Georgiana Date: 12/17/2005
    Comment:

    AS I understand it, Medicare will not cover theopen vertical banded gastroplasty, (also known bymany as the "Fobi Pouch"). It is an unfortunatechoice not to cover this procedure as statisticshave shown that the Fobi Pouch is one of the mostsuccessful surgeries, with the lowest rate ofrecidivism (weight regain), and a lower thanaverage morbidity and mortality rate. Because ofthe post surgical vitamin regimin, Fobi patientstend to be some of the healthiest of weight losssurgery patients over

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    Russell, Melissa Date: 12/17/2005
    Comment:

    I dont understand why you would want to pull coverage for this procedure?? You mean to tell me you think it would be more cost effective for you to keep covering these people who are obese with their hospital stays, lab work, medication alone, primary care doctors. ect that goes hand in hand with obesity. You all really need to set back and rethink this before you jump in and pull the plug on it. Melissa Russell

    DUKE, BRUCE Title: Section Head, General Surgery
    Organization: ConemaughMemorial Medical Center
    Date: 12/17/2005
    Comment:

    I believe based on previous experience that severely obese patients over 65 years of age who meet NIH consensus criteria for bariatric surgery deserve the only opportunity to cure or control their comorbidities. Since it is well established that medical management fails in atleast 97% of patients, age should not be a restriction. Age is not a restriction for other serious forms of surgery.

    The ASBS and ACoS has established registry programs which are recently implimented and

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    Fillio, Linda Date: 12/17/2005
    Comment:

    Bariatric surgery is NOT a wasteful procedure. Obesity is a national epedemic and we are all part of the problem. This is a chance to be solution based and allow folks who truly suffer to regain health. In the long run (please thing globally) costs will be less, your people will be happier and the nation will benefit. Please do not be narrow sited.

    Haas, Rita Date: 12/16/2005
    Comment:

    I think if medicare would cover more surgeries for obesity, it would be cheaper in the long run. Comorbities the results from obesity is more costly in doctor visits, prescriptions and hospitalization.

    Archer MD, Stephen B Title: Director, Bariatric Surgery Program
    Organization: St. Charles Medical Center
    Date: 12/16/2005
    Comment:

    I would strongly urge that you reconsider the age over 65 population. The evidence for increased mortality does not address the improvement in quality of life for the vast majority of patients who survive. Surgery is the only effective intervention and doing nothing for this life-threatening disease is similar to doing nothing for patients with symptomatic aneurysms because the survival is poor.

    Sharkey, Cheryl Date: 12/16/2005
    Comment:

    Please don't consider dropping coverage for the Douodenal switch as it is a much superior surgery and allows the best quality of life for patients compared to any of the gastric bypass procedures.As we all know if Medicare doesn't cover a procedure then private insurances refuse to also and the majority of people on Medicare cannot afford to travel to Spain or Brazil to have this surgery as private pay in the US is cost prohibitive.

    Lee, Kathleen Date: 12/16/2005
    Comment:

    This approach seems very age discriminatory to me. Each patient, no matter what their age, should be treated on a case by case basis and not automatically eliminated from consideration strictly because of age. I do not believe that there is enough conclusive evidence to arbitrarily eliminate an entire population from receiving a surgical procedure that has proven to improve overall health and eliminate numerous health problems related to morbid obesity. I would like to see data used from

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    Cavazos, Sonny Title: physician/surgeon
    Organization: Texas Center for Medical and Surgical Weight Loss
    Date: 12/16/2005
    Comment:

    It is sad to see such a poorly conceived notion adversely affect a group of people who could so greatly benefit from bariatric surgery. Physicians should be deciding who is a good candidate for treatment because they are the most appropriate individuals to do so.

    Deutzer, Juergen Title: Bariatric Coordinator
    Organization: Scripps Mercy Hospital
    Date: 12/16/2005
    Comment:

    Denying morbildy obese patients bariatric surgery just because they are over 65 is unfair. Selection of appropriate candidates should be done on an individual basis. Many patients over 65 who have had this kind of surgery in the past, can enjoy many more years without comorbidities they had prior to the surgery.

    LePort, Peter Date: 12/16/2005
    Comment:

    To deny bariatric surgery to severely obese patients simply because they are over 65 is unfair. First, there is no other effective treatment for morbid obesity. Second, we do not have such rules for other operations. Third and most importantly, the decision is based upon very limited data.

    Instead, a better approach would be to approve bariatric surgery for patients over 65 provided that each patient is entered into the bariatric surgery registry of the Surgical Review Corporation

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    Thompson, Lois Title: Retired Health Informanation Management Manager
    Organization: Acute Care Hospital
    Date: 12/16/2005
    Comment:

    I do not understand the logic of the recommendation of non coverage of bariatric surgery for persons over 65 yoa. I think the death rate comparison should be with persons who have had the surgery vs persons who have not had the surgery.

    I think comparing many other procedures performed on under 65 to over 65 would come up with similar findings.

    Adamms, Diane Susann Date: 12/16/2005
    Comment:

    My opinion counts and you must know upfront that I am angry....

    There is no way that anyone - medical profession or government of our people - no one is even listening to the true experiences of even the most 'successful' WLS patients.

    Most of the after-surgery patients are not relating their honest experiences out of shame upon themselves, that they have not done what they needed to do to have a successful surgery.

    They are prematurely aging! They are in pain. They

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    Smith, Elizabeth Title: RN
    Date: 12/16/2005
    Comment:

    Your decisions regarding bariatric surgery are short sighted and very negligent. The treatment of these patients to reduce their weight is beneficial not only to the patient but to the entire healthcare system. The cost of treating these people long term for Diabetes, Hypertension, Heart Disease and any number of other diseases far out reaches the cost of this surgical treatment. It not only decreases the stress on an already over taxed health care system it returns these people to strong

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    Pories, Walter Title: Professor of Surgery
    Organization: East Carolina School of Medicine
    Date: 12/16/2005
    Comment:

    To deny bariatric surgery to severely obese patients simply because they are over 65 is unfair. First, there is no other effective treatment for morbid obesity. Second, we do not have such rules for other operations. Third and most importantly, the decision is based upon very limited data.

    Instead, a better approach would be to approve bariatric surgery for patients over 65 provided that each patient is entered into the bariatric surgery registry of the Surgical Review Corporation

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    Cordero, Chelle Date: 12/15/2005
    Comment:

    Today the subject is Weightloss Surgery and age 65... and tomorrow what will it be? What procedures, treatments or medications will we look to deny? And what parameters will we use? Too old, too young, too poor, too uneducated, too white, too black...

    It is NOT for the "almighty Medicare & Insurance Deities" to decide whose life is valuable and whose life is not worth their year-end profits.

    Let the doctors be doctors and decide if this is the right treatment to improve, or even save,

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    Kothari, Shanu Date: 12/15/2005
    Comment:

    Patients > 65 have the option to undergo elective coronary artery bypass, joint replacement, peripheral vascular surgery with equivalent morbidity and mortality; it is discriminatory to block access to bariatric surgery for this age group.
    Courcoulas A, Schuchert M, Gatti G, Luketich J. The relationship between surgeon and hospital volume to outcome after gastric bypass surgery in Pennsylvania: a 3-year summary. Surgery 2003; 134:613-621.
    Nguyen NT, Paya M, Stevens CM, Mavandadi

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    Bessler, Marc Title: Assitant Professor of Surgery
    Organization: Columbia University
    Date: 12/15/2005
    Comment:

    I congratulate CMS for making the decision to cover bariatric surgery specifically Gastric Bypass and Adjustable Gastric Banding for the morbidly obese. I am concerned about the decision to exclude this treatment for patients age 65 and over. While I agree that there is limited data on outcomes in this group of patients the data that is available documents good weight loss outcomes. In fact we recently presented our data on this and I am sending a copy of that presentation under seperate

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    Mehr, Mahzad Date: 12/15/2005
    Comment:

    Please do not exclude the Bariatric Surgery Duodenal Switch(BPD/DS) from Medicare coverage. This procedure is the most effective weightloss surgery for some. Specially the fact that the other weight loss surgery does not work and is not suitable for some patients.

    Cornell, Carmen Date: 12/15/2005
    Comment:

    Although I understand that this surgery is riskier for patients over a certain age, we are also living longer today. Health care costs for aging obesity are going to be tremendous. In the long run I firmly believe that Bariatric Surgery will be more cost effective and allow for much better quality of life. Having been a CNA, I have seen what it's like to be morbidly obese and unable to care for oneself as you get older.

    Koester, Martha Date: 12/14/2005
    Comment:

    According to the October 5th JAMA, weight loss surgery is more dangerous than previously thought. Half of patients 75+ die from it. This is an outrage! Even for the 35-44 year age group, 4% is too much.

    antinori, stephenie Date: 12/14/2005
    Comment:

    I AM TOTALLY AGAINST MEDICARE TAKING AWAY SURGERIES FOR THE OBESE PEOPLE WHO ARE 65 YEARS AND OLDER. THEY DESERVE EVERY CHANCE THEY CAN GET TO LIVE A LONGER AND HEALTHY LIFE.

    Hottell, Shawn Date: 12/14/2005
    Comment:

    There is risk in everything. I ask, "is this surgery a reasonable risk?" Let the surgeons determine this, not the government! I would say that surgery for a person, over 65, can include death and complications. Just as in any age. Sure older folks may have more complications and risk. But is shouldn't be left up to the government to decide!

    Kasserman, Sherry Date: 12/14/2005
    Comment:

    In all reality bariatic surgery is a life saving operation. I think medicare and medicaid should cover this to save lives.

    Alexander, J. Wesley Title: Prof of Surgery; Director
    Organization: Univ of Cincinnati; Ctr for Surgical Weight Loss
    Date: 12/14/2005
    Comment:

    I would like to make several comments regarding the proposed changes for Medicare coverage for bariatric procedures. Apparently, it is proposedthat patients 65 years of age or older should not be covered for bariatric procedures because of an increased risk cited by a recent study by David Flum in JAMA. It should be evident that the study by Flum is flawed by the fact that there was no appropriate control group. It is likely, in fact, that the patients who did have a bariatric procedure had

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    McDonald, Janet Date: 12/14/2005
    Comment:

    Biliopancreatic Diversion w. Duodenal Switch (BPD/DS)is the best weight loss surgery offered! Please do not exclude it from coverage and deny others the best surgery for obesity! Please!

    Freeman, Bryan Title: Surgeon
    Organization: Freeman & Company Bariatric Surgery Center
    Date: 12/14/2005
    Comment:

    I have performed over 1800 Roux-En-Y gastric bypass surgeries. Many of which were Medicare patients. Our patients over and under the age of 65 have done very well. Our mortality rate on Medicare patients is 0% (no deaths) Bariatric surgery can provide patients with an opportunity for improved quality of life, as well as,increase their longevity. Bariatric surgery offers many patients suffering from Hypertension, Diabetes, Sleep Apnea, Heart Disease, etc. an opportunity to be free from

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    Bishop, M.Ed, Amy Date: 12/14/2005
    Comment:

    When it is medically necessary for an individual to undergo bariatric surgery, it is only logical that he or she should have the option to undergo the research-based effective procedure that best fits the individual needs of the person. The biliopancreatic diversion/duodenal switch is a procedure that is comparable to the gastric bypass, but fundamentally different in that it utilizes less restriction and more malabsorption. Both of these are utilized in gastric bypass. For some

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    Smith, Edna Date: 12/14/2005
    Comment:

    Please do not exclude any type of surgery for the obese. People's health will get better, and they will not need as many medicines as they will need without it.

    Praytor, Alana Title: PACS/RIS Administrator
    Organization: Norman Regional Hospital
    Date: 12/14/2005
    Comment:

    Please reconsider the proposal to deny gastric bypass coverage to medicare patients over the age of 65. Gastric bypass is a new lease on life. It can improve so many chronic health issues. Spend your money on their chronic health issues or help someone improve every aspect of their life.

    Mitch, Ann Date: 12/14/2005
    Comment:

    Why should any version of this surgery be based upon a person's age? Why not base it upon whether or not they meet the criteria for the procedure, what co-morbidities they have, what are their surgical risks and what is the value of having the procedure? Most people in their 70's are acting and looking like people used to do in their 50's. Over the years the RYN gastric bypass seems to have become thegold standard, but the upcoming research tends to show that other procedures, such as the

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    Hungness, Eric Date: 12/13/2005
    Comment:

    I am a bariatric surgeon at the University of Chicago. I have two comments regarding the Medicare coverage proposal for bariatric surgery. The first is that the duodenal switch does have a role in the surgical treatment of the super obese. In numerous single center studies and in our institutions experience, the weight loss is superior to that of RYGB or Lap-band for this subset of patients. It is our surgery of choice for the super-obese. The ongoing NIH-sponsored Longitudinal

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    Alverdy, John Title: Professor of Surgery
    Organization: University of Chicago
    Date: 12/13/2005
    Comment:

    I am a practicing bariaric surgeon and a professor of surgery at the University of Chicago. I have been practicing bariatric surgery for 15 year and take care of very high risk patients in an urban setting. Numerous studies have shown that the patients that need bariatric surgery the most (i.e the highest weight, most medical problems) are the least likely to undergo an operation. This group of high risk, high weight patients exert the highest finacial burden to the system as a result of

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    Burke, Jeri Title: Registered Nurse
    Date: 12/13/2005
    Comment:

    Thank you for the opportunity to respond to the Medicare proposal for obesity surgery. My employment history has been in the health care field as a registered nurse with experience in areas of critical care, triage, home health, insurance evaluation, utilization management, smoking cessation and currently disease management. My following comments are not quick judgments but rather observations of the typical patient in our health care system. Numerous chronic disease processes begin with

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    Stimson, Bonnie Date: 12/12/2005
    Comment:

    This is an exceptionally positive move for the participants who utilize Medicare/Medicaid services/coverage. The health risks and/or comorbilities brought on by obesity steal an enjoyable life from the patient. At the same time treatements for those same comorbities cost taxpayers millions of dollars each year.

    The availability of Bariatic Surgery as a treatment for Morbid Obesity will allow patient and doctor to make plausible health decisions, which could remedy or reduce

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    Jacques, Jacqueline Title: Chief Science Officer
    Organization: Catalina Lifesciences, LLC
    Date: 12/12/2005
    Comment:

    As a health professinal working in after care providing nutrition programs for bariatric surgical patients, I strongly support access to weight loss surgery procedures for qualified individuals over the age of 65. In patients who are carefull selected for surgery, and who are cared for by qualified health professionals, age should not be a primary criteria. Older patients should be able to have excellent outcomes with improved health and quality of life with bariatric surgery. Equally

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    Hogenson, MS, RD, Sherlyn Title: Coordinator of Weight Management Services
    Organization: Ingham Regional Medical Center
    Date: 12/12/2005
    Comment:

    I agree with the age limit of 65 for bariatric surgery, but I would suggest an increase in the limit upon recommendation of the surgeon and the primary care physician or internal medicine specialist for specific individuals.

    I am pleased to hear that coverage is being considered for weight management programs. I would recommend coverage for comprehensive, hospital based programs staffed with health professionals, including registered dietitians. These types of programs have

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    Lord, Jeffrey Title: Director of Bariatric Surgery
    Date: 12/12/2005
    Comment:

    Dear Members of the NCD-Medicare.
    I am a fellowship trained Bariatric Surgeon. I perform primarily Bariatric Surgery. This includes Lap RYGBP, Lap Bands and sleeve gastrectomies in the super obese which later get converted to Lap RYGBP. I have several significant concerns.

    1) 5% of our practice involves Florida patients who are > 65 years of age. Denial of access to bariatric surgery I feel is a significant disservice to many patients. Our complication rate for > 1000

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    Peters, William Date: 12/11/2005
    Comment:

    To whom it may concern. I write to you in support of bariatric procedures from which you apparently plan to withdraw support and payment. Also, though I don't generally believe that politics has the right to control science, that you have added payment for a procedure that is not ready to be advanced.

    First, open vs laparoscopic procedures is a surgeon's choice based on the circumstances in an individual patient. Because the operation should be the same, there should be no basic

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    Loving, Christine Date: 12/11/2005
    Comment:

    Ladies and Gentlemen, Please do not discontinue coverage of obesitysurgery for those in need. There is not a currentsubstitute that is effective in the treatment ofobesity. Until then, this option should still beavailable when there is no other choice Also, it is not in this country's bestinterest to start descriminating because of ageunless there is another medical reason for notdoing surgery.Thank you,
    Christine Loving

    Zuccala, Keith Date: 12/11/2005
    Comment:

    I am a bariatric surgeon and I would like to commend Medicare for its decision to endorse baraitric surgical coverage for its patients. There are some particulars with which I take exception however. I feel that the American Society of Bariatric Surgery has done an outstanding job at attemting to ensure the quality of baraitric operations being done in this country through their Centers of Excellence program. Myself, my practice and my hospital went through the process and I firmly

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    Frater, Lara Title: Author
    Date: 12/11/2005
    Comment:

    While I might disagree with that excess weight might be deprimental to ones health, I believe the risks of gastric bypass (which have a 2% death rate and higher as one gets older. Health risks for those over 75 were 40% for women and 50% for men) are bigger than the risks of excess weight.

    Instead of using medicare to pay for gastric bypass they should pay for healthier meals and fitness programs.

    Rajajoshiwala, Paresh Date: 12/10/2005
    Comment:

    You would not deny treatment for breast cancer, colon cancer or pancreatic cancer to elderly patients. Some of this illness have treatments that are with debatably marginal outcomes. The obesity treatment has been proven to be beneficial and in long term cost effective, I think it is a great injustice to deny percentage of our population effective treatment solely based on age criteria. What ever happen to no descrimination based on age/race/religion etc motto. What sort of example are you

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    Stone, Brenda Title: coordinator
    Organization: human services
    Date: 12/10/2005
    Comment:

    I believe this is a very important surgery and really needs to continue. These people are on medication for all sorts of others complications and by having the surgery their chance of being taken off the medications are very high. The surgery would be much easier and cheaper than continuing all of the medications for the entire life of a person. Also, these people may be able to return to the work force which therefore, would lower the unemployment/ disability rate.. Please keep this

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    hernandez, sherry Title: TRYING TO HELP OUR RIGHTS
    Date: 12/10/2005
    Comment:

    I JUST DO NOT UNDERSTAND THE LOGIC OF TAKING AWAY THIS BENIFIT/WHICH IS A TOOL. DO THE INSURARNCE COMPANY RELIZE HOW MUCH MONEY THIS SURGERY WOULD SAVE THEM IN THE LONG RUN? MORBID OBESITY IS A SICKNESS/BELEIVE ME I WOULD NOT WISH THIS SICKNESS ON ANYONE.YOU WILL TAKE CARE OF A SICKNESS SUCH AS ACHOLOL/OR DRUGS TO BE COVERED, BUT NOT COVER SURGERY FOR MORBID OBESITY! PLEASE DON'T STOP HELPING THE PEOPLE THAT NEED THE HELP NO MATTER WHAT AGE THEY ARE. I THINK THAT SHOULD BE LEFT UP TO THE

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    Invidiato, Ramona Date: 12/09/2005
    Comment:

    Bariatric surgery has been found to be the most proven method for those who have tried all their livesto lose weight but can't . It should not only be extended for those who are morbidly obese but forthose who are 35 MBI and can document that traditional methods have not worked.I only hopethe insurnace companies recognize that this is a disease and stop throwing up the hurdles that they do.

    Stier, Sally Date: 12/09/2005
    Comment:

    PLEASE PLEASE do not decide for anyone which surgery is best for them. Everyone is different including your insureds. The RNY might work for someone but what if it doesn't for the next person. The BPD/DS is so proven to work it's not even funny and it can't be reversed like other surgeries. If a surgery is reversed you paid for it for no reason and yours and our money is down the tubes. Please gather all of the facts with an open mind!!

    Prather-Payne, Brandy Date: 12/09/2005
    Comment:

    It is amazingly shortsighted to think of the elimination of Medicare and Medicaid coverage for the Duodenal Switch procedure, and also elimination of coverage of weight loss surgery for people over the age of 65, among other things. Given the tremendous amount of other health related costs associated with morbid obesity, it seems crucial for surgeries such as these to be covered in order to avoid further costs that occur due to the medical effects of obesity. Although this decision doesn't

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    Maher, James Title: Professor and Chairman, Division of General Surger
    Organization: Virginia Commonwealth University
    Date: 12/09/2005
    Comment:

    Virginia Commonwealth University would like to submit it's data in patients over the age of 65. We have performed bariatric surgery in 26 patients with ages ranging from 65 to 74 years. There have been no 30, or 90 day or in-hospital deaths in these 26 pts done over 7 years. The mean percentage of excess weight lost was 50%and this was maintained for 3 yr. There was: 40% resolution of hypertension at 1 yr, 60% resolution of diabetes, 92% resolution of stress urinary incontinence, 100%

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    Moorehouse, Brett Date: 12/09/2005
    Comment:

    Medicare should cover the gastric bypass procedure at hospitals that have performed a high volume of cases and in hospitals that have the equipment and trained staff. Advances in tools and surgeon technique are making this a less risky surgery. The surgery has proven to resolve other co-morbidities, which if untreated, will ultimately harm the patient and result in increased cost.

    Facundus, Edward Organization: Alabama Surgical Associates
    Date: 12/08/2005
    Comment:

    I am a ABS certified general surgeon practicing in the Huntsville, Alabama area for over 10 years. I have been performing laparoscopic roux- en-y gastric bypasses since 1998 within a comprehensive surgical weight loss program. I have performed over 1500 cases.

    In my experience, there is no significant difference in age as related to outcomes. This point is made by the authors of the recent JAMA article by Dr. Flum. My experience is limited in less than 2% of my patients are over

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    Seitz, Sue Date: 12/08/2005
    Comment:

    I feel Medicare is doing a diservice to those who are morbidly obese and diets haven't helped. This surgery has helped many people live more quality of life and experience better health, in the long run costing Medicare a lot less then otherwise the complications of the morbidly obese have. So many of us could tell you stories of how diet after diet has failed only to find we gain more opounds when we relax finding we can't stay on a cardboard diet or the manyh other types out their.

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    Chang, Craig Title: Bariatric (weight-loss) surgeon
    Date: 12/07/2005
    Comment:

    You people at CMS are idiots! You cite one article by Dr. Flum about early mortality and neglect to acknowledge that LATE mortality is lowered (See another article by Dr Flum-Impact of gastric bypass operation on survival:A population based analysis. Journal of Am Coll of Surgeons 2004; 199:543-551). Has anything else OTHER than surgery combined with lifestyle change ever worked to help obese patients lose (and keep off) the excess weight? You want to eliminate surgery for patients over 65.

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    Gomez, Guillermo Title: associate professor
    Organization: university
    Date: 12/07/2005
    Comment:

    1) Outcome and not number of cases alone should be the factor to recognize and grant privilages for bariatric surgery. Beyond a critical point, systems can underperform due to exhaustion. Pushing for numbers will dilute resources and compromise quality.

    2) Physiologic age and reserve should prevail over the strict arbitrary age of 65 years old.

    3) Leaving 65 years or older out is excluding a main body of beneficiaries for which the system is responsible for. Sounds

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    Shah, Paresh Title: Director Laparoscopic Services
    Organization: Lenox Hill Hospital
    Date: 12/07/2005
    Comment:

    I am writing to urge consideration of coverage for bariatric surgery to all Medicare beneficiaries regardless of age. There is ample data that while the risk may be higher, the benefit is equally great for these patients suffering from the chronic disease of Morbid Obesity. Our own research from the Lahey Clinic in Mass., presented at the Society of American Gastrointestinal and Endoscopic Surgeons Scientific Meeting in 2002 demonstrated equal improvements in health with no increase in

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    Williams, Cathy Date: 12/07/2005
    Comment:

    In the July/August 2005 issue of Surgery For Obesity and Related Diseases, a report on a retrospective series of 27 patients >65 years undergoing bariatric surgery (lap band or gastric bypass) concluded that the operations are safe and gained significant benefit in terms of weight loss. The study shows progress over prior studies in that we have validation in the >65 yr age group. Given that this age group has increased risk of dying due to co-morbidities, we do need to increase awareness

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    Stiles, L.e.Sasha Title: md
    Organization: Kaiser Permanente
    Date: 12/07/2005
    Comment:

    BARIATRIC SURGERY FOR THE TREATMENT OF MORBID OBESITY: I am the Medical Director for Bariatric Surgery At Kaiser Permanente Northern California, South San Francisco. I have testified before MCAS at the last public hearings on bariatric surgery in 2004. I would like to add my comments as a primary care physician and subspecialist in severe obesity and bariatric surgery in an HMO setting.

    1. AS my previous comments have stated, what is critical is that a responsible

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    Meador, RN, Jill Title: Bariatric Nurse Coordinator
    Organization: VCU Medical Center
    Date: 12/07/2005
    Comment:

    As a bariatric nurse coordinator for almost 12 years, I have had the intense personal and professional satisfaction of seeing the lives of literally thousands of patients saved and improved by bariatric surgery. Our research article, Effects of Bariatric Surgery in Older Patients (Sugerman et al), presented data on 80 patients between the ages of 60 and 74 years old. These data clearly showed immense medical benefit from bariatric surgery in older patients, inlcuding (but certainly not

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    argotte, alex Date: 12/07/2005
    Comment:

    i am for any coverage regarding bariatric surgery. i also believe that the age limit to be extended beyond age 65. i strongly beieve that is crucial to provide full coverage to morbidly obese patients

    St. Marie, Gloria Title: Executive Secretary
    Organization: UMass Memorial Medical Center
    Date: 12/07/2005
    Comment:

    I have been an executive secretary for a bariatric surgeon for the last six years. I have seen many more successful surgeries than unsucessful ones. As with any kind of surgery, there are pros and cons for which the patient must decide, and the pros for this surgery are numerous, such as decreasing the use of medications and prolonging ones life. However, I do feel there needs to be more specific criteria for the process of being approved for bariatric surgery, especially in the area of

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    Wittcoff MD, Harold P Title: Chief of QRM
    Organization: Kasier Permanente
    Date: 12/06/2005
    Comment:

    Opening up Bariatric surgery for Medicare ccoverage for patients under 65 presents a real dilemma. One cannot sign onto Medicare until age 65 except for special circumstances, so who are you really covering.?? How are you going to reimburse Medicare HMO's that have to do this surgery which can result in some very difficult, long term, costly complications.???

    By Medicare forcing the issue on Bariatric surgery, the pressure on Insurance companies to offer Bariatric surgery will be

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    Ho, Sam Title: EVP Health Services, Chief Medical Officer
    Organization: PacifiCare Health Systems
    Date: 12/06/2005
    Comment:

    PacifiCare applauds the effort that CMS has undertaken preparing the above mentioned National Coverage Determination regarding Bariatric Surgery for Morbid Obesity in Medicare Beneficiaries. We still however, continue to have some reservations as to its breadth of coverage, as well as certain deficiencies in its criteria for participating centers.

    In the current draft NCD, CMS proposes “coverage for Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding are reasonable

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    Ferguson, Robin Date: 12/05/2005
    Comment:

    Please support ALL individuals for Bariatric Surgery for the support of a healthier life even at the age of 65 and older. Everyone has that right. Please offer or continue to offer this surgery. I greatly appreciate your efforts for a healthier lifestyle for all concerned. Peace be with you all. Robin Ferguson

    Lamb, Jerome Date: 12/05/2005
    Comment:

    I should have added that current clinical evidence indicates that the GR-DS is more effective than the RNY procedure. A large number of RNY patients are now requiring revisions or have had the procedure fail them. A lot of those who are having revisions are going to the better GR-DS procedure by highly experienced surgeons.

    Bagley, LeRoy Title: Full-time Student
    Organization: Sonoma State University
    Date: 12/05/2005
    Comment:

    This is a slap in the face of those who truly need help. If you are willing to cover rehab for drug/alcohol abuse and assist with quitting smoking why are you not willing to help those who are addicted or abuse food. THis is a politically correct double standard that needs to be halted. If you are an alcoholic/druggie/smoker you can for the most part just avoid the things that caused you to start down that road. But for the obese, you cannot just stop eating. This is a daily battle that no

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    CRONE, CANDY Date: 12/05/2005
    Comment:

    I THINK THAT THE DS SHOULD STILL BE APPROVED. IT HELPS SOOOO MANY PEOPLE ESP EXTREMELY OVERWEIGHT PEOPLE. IT IS THE ONLY WEIGHT LOSS SURGERY KNOWN TO CURE DIABETES. IT HAS LONGER LASTING RESULTS AND A BIGGER WINDOW. PLEASE TAKE THIS UNDER CONSIDERATION AND CONTINUE TO COVER THIS FOR PEOPLE. THANK YOU CANDY

    Aranow, Jonathan Title: Chairman, American College of Surgeons (CT Chapter
    Organization: ACS (CT)
    Date: 12/05/2005
    Comment:

    Year
    Total Obesity Procedures 2001
    431 2002
    864 2003
    1,603 2004
    1,957
    65y and older 1 8 13 25
    Percent 65y and older 0.23 0.93 0.81
    1.28
    Mortality all ages 2 2 0 2
    MEDICARE FFS 29 38
    68 86
    MEDICARE MANAGED CARE 2
    1 6
    8

    As you can see, we are dealing with a very small proportion of patients in the over 65yo age range (less than 1% in 2001-2003

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    Lefkowitz, Michele Title: Registered Dietitian
    Organization: Cleveland Clinic FLorida
    Date: 12/05/2005
    Comment:

    I am a registered dietitian and I have been working with bariatric patients for almost 3 years now. Our program has close to 1900 bariatric patients. I have the chance to witness daily, the positive change bariatric surgery can have in the life of a morbidly obese person. Daily, I see people transform not only physically but mentally and spiritually. People that are given a second chance in life.

    I have been a dietitian for 11 years and not until I started working with this

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    ZAK, SABINA Date: 12/03/2005
    Comment:

    I AM QUITE CONCERNED WITH THE DECISION THAT MEDICARE HAS REACHED IN REGARDS TO:

    1. BLOCK ACCESS TO PATIENTS 65 Y.O AND OVER;
    2. BLOCING ACCESS TO THE TWO-STAGE PROCEDURE.

    AT OUR PRACTICE, WE HAVE BEEN PERFORMING WEIGHT LOSS SURGERY SINCE 2002. THE MAJORITY OF OUR PATIENTS ARE YOUNGER THAN 65 Y.O, HOWEVER OUR OLDER PATIENT THAT ARE 65 Y.O AND OVER (OUR OLDEST PT. WAS 67 Y.O) HAVE HAD WEIGHT LOSS SURGERY WITH SAFE AND HEALTHY OUTCOMES. THESE PATIENTS WERE ABLE TO

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    Borger, Barbara Date: 12/03/2005
    Comment:

    I feel very strongly that limiting the age a person can be for a gastric bypass surgery goes against all common sense and rights of the people. What will be next, that persons over a certain age should not be allowed to have surgeries for cancer or heart bypass and on and on? The facts that gastric bypass surgery can improve health and lengthen the life are only two of many reasons it should be approved no matter what the age of a person. The doctor is the one to decide if the person it

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    Pilcher, John Date: 12/03/2005
    Comment:

    Sirs, As a surgeon actively participating in the care of morbidly obese patients, I am pleased that you are working to engage this topic in a careful and scientific way.

    I request that you give additional consideration to the non-coverage position proposed for beneficiaries of age greater than 65 years. The medical literature demonstrates that Weight Loss surgery can be a safe and effective option for people older than 65 years, especially if the surgery is performed in a

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    Green, Alocasia Date: 12/03/2005
    Comment:

    Bariatric surgeries in their many varieties (but most specifically, the BPD/DS - by far the most successful surgery for establishing and maintainint a normal body mass index) are and will be saving the medical industry MILLIONS - if not billions - of dollars in the treatment of obesity-related illnesses. Treatment of the comorbidities of obesity such as diabetes, insulin resistance, sleep apnea, hypertention, high cholesterol, heart disease, vascular conditions, congestive heart failure,

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    Burke, Dawn Date: 12/03/2005
    Comment:

    Medicare would be making a grave error in not covering the duodenal switch. There are less side effects with the duodenal switch than with the gastric bypass, the amount of total weight loss is greater, and the patient is able to eat normally, with no dumping syndrome. There are many more benefits that I am not able to list here, and Medicare should investigate this futher before arbitrarily dismissing the duodenal switch from coverage. Thank you.

    Kidd, Lance Title: Assistant Vice President
    Organization: Bank of America
    Date: 12/02/2005
    Comment:

    The decision to remove the BPD/DS and two-stage procedures from coverage is remarkably short-sighted, and ignores the wealth of statistics that show what a powerful tools these procedures are for those suffering from obesity. The quality of life that these surgeries restore is remarkable, and often supasses that of "less technical" surgical options.

    I highly recommend that this decision be reconsidered.

    FREDERICK, JULIE Title: Clinical psychologist
    Organization: Akots and Frederick, P.C.
    Date: 12/02/2005
    Comment:

    I am concerned that your proposed coverage for bariatric surgery does not require and support a role for psychologists. It is my opinion that psychologists play a critical role in assessing psychological issues prior to surgery through a psychological evaluation. They are also essential for ensuring good post-operative adjustment and compliance. Psychiatry is not an appropriate substitute and should not be given preference over psychological treatment.

    Hansen, Kyle Title: Manager of Business Development
    Organization: Sutter Health
    Date: 12/02/2005
    Comment:

    I think the approach CMS is taking on this coverage isssue is in the right direction. I would advise that CMS engage the american society of bariatric surgery as a facility and surgeon quality approval organization, including credentialling. I agree w/ the use of CED but would like to see a shorter trial period vs. historically long adoption periods, particularly given the standing history of bariatric surgery and the data available.

    Lastly, I would adhore that CMS provide the

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    Hayes, Paul Date: 12/02/2005
    Comment:

    I am in favor of Medicare adding coverage for this treatment of the chronic disease process of obesity.

    I believe this will lower overall medicare spending for medical treatement related to comorbidities that will be eliminated.

    I believe the decision regarding age and appropriateness should be left up to the surgeon up to the age of 70.

    Russo, Jennifer Title: Counseling Support
    Organization: Serco Inc. Contractor for the Department of Defense ARMY
    Date: 12/02/2005
    Comment:

    I feel it is unfair for insurance companies to dictate what surgery someone should have. There are many downfalls to the RNY and the band. For some people, especially morbidly obese people the BPD/DS is their last resort. It has the highest weight loss percentage and when people follow the guidelines for living with the BPD/DS they have longer, healthier lives. It cures most diabetes and other comorbitities and I don't understand why it isn't realized that this saves the insurance

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    Stein, Anne Date: 12/02/2005
    Comment:

    Dr. Anthone of Nebraska, Dr. Peter Crookes of California, Dr. McConnell of Oregon, Dr. Gagner of New York, and many other surgeons (50 or more) in the United States that perform the Duodenal Switch MUST be contacted BEFORE such a decision to EXCLUDE THEIR SPECIALTIES are withdrawn from Medicare coverage.

    Have these surgeons been contacted? Are they aware of this heinous crime against the super morbidly obese? (Not being able to received their treatment/surgery of choice?)

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    Ali, Amjad Title: Dr
    Organization: Hamot Medical Center
    Date: 12/01/2005
    Comment:

    I welcome the new NCD. I have the following concerns.

    Coverage for those 65 and over I know of many patients who are older than 65 and have done very well with weight loss surgery. I believe in experienced hands, people older than 65 have very good results with weight loss surgery. It is a fact that morbid obesity in patients older than 65, like other age groups does not have any other effective treatment. Denying weight loss surgery to those patients is akin to death sentence as

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    Ames, Jenifer Date: 12/01/2005
    Comment:

    I am very upset with your decision with the BPD/DS surgery. This surgery is one of the best out there. If you do your research properly you would see that this is the best surgery to go for. It has the best success rates. This would eliminate any further costs down the road as well. Sometimes I wonder about you people. You'll pay thousands of dollars for 3 to 5 surgeries for the same thing but when you can pay once for something and be done you take that away. INSANE! I think you

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    Brennan, Psy.D., Stephen Date: 12/01/2005
    Comment:

    While I agree to limit bariatric surgery to those under 65, I am quite concerned about patients being evaluated pre-operatively by only psychiatrists. These patients are highly motivated to have surgery, if not too highly motivated. None of them freely admit to eating disorder-type behaviors or other problems that could jeapordize their preoperative psychological evaluation recommendations. Only psychologists are trained in the administration and interpretaion of various tests and

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    Smith, Brenda Date: 12/01/2005
    Comment:

    Coverage for weight loss surgery should continue. The BPD/DS is a great tool for a person to regain their health. I would think your actual costs for someone who after surgery would no longer have diabetes, and many other co-morbidities would actual be lower. Not to mention this persons' quality of life would be so much better.

    Nelligan, Julie Title: Clinical Psychologist
    Organization: Portland VA Medical Center
    Date: 11/30/2005
    Comment:

    As I understand it bariatric pre-surgery psychiatric evaluations are going to be required by "staff and consultants in psychiatry," which does not include psychologists. Psychologists are extremely qualified to conducted these evaluations and it would do a dis-service to Medicare beneficiaries to be denied access to their expertise. Psychologists who conducted these evaluations are quite skilled in performing evidenced-based evaluations and incorporating multi-faceted data such as is

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    Rosenzweig, Psy.D., Susan Title: Psychologist
    Date: 11/30/2005
    Comment:

    "Each institution will have staff and readily available consultants in cardiology, pulmonology, rehabilitation and psychiatry who have prior experience with bariatric surgery patients."

    I believe that the "psychiatry" requirement should instead be a requirement for consultants in behavioral health who have prior experience with bariatric surgery patients.

    By restricting the consultant field to psychiatry instead of all the behavioral health professions, the proposal

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    O'Driscoll, Megan Title: Manager of Bariatric Services
    Organization: Bariatric Institute of Wisconsin
    Date: 11/30/2005
    Comment:

    To Whom It May Concern;
    We created a bariatric program and began performing bariatric procedures in June 2001. Our experience with clients over the age of 65 has been excellent. It would be unfortunate if treatment for morbid obesity was denied to clients over the age of 65 based on one research paper. The JAMA article you refer to does not represent data from an ASBS Bariatric Surgery Center of Excellence (COE). An ASBS COE represents surgeons who maintain high volumes, out standing

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    Herron, Daniel Title: Chief, Bariatric Surgery
    Organization: Mount Sinai School of Medicine
    Date: 11/30/2005
    Comment:

    I strongly disagree with the plans to disallow bariatric procedures for the 65 and over population. We have recently reviewed the Mount Sinai Hospital experience with 60 year old and older patients and found excellent results with very reasonable complication rates. In carefully selected older patients, bariatric surgery can be performed safely with good weight loss and low complication rates.

    Hornbostel, Phillip Title: Bariatric Surgeon
    Organization: ASBS/ACS Fellow
    Date: 11/30/2005
    Comment:

    As a dedicated laparoscopic bariatric surgeon, I have provided surgical intervention for patients with morbid obesity to achieve weight loss, over the past 4 years. During this time, I have provided service to 15 patients over the age of 65, and to over 100 Medicare/Medicaid beneficiaries of all ages. We are proud of our record of ZERO mortalities during this time, as well as successful weight reduction (>65% of excess weight) in >75% of patients, with no patient failing to

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    Floden, Linaea Title: Program Coordinator
    Date: 11/30/2005
    Comment:

    As coordinator of a Diabetes and Nutrition Center in an outpatient hospital setting, I feel that Medicare should consider more aggressively covering Medical Nutrition Therapy with an RD,LN and individual consults with an Exercise Physiologist (and reimbursing at a competitive rate for these services to ensure they are still cost effective for the facility to provide) before allowing for these high cost, and in some casestrendy, approaches to preventable and otherwise treatable problems.

    Howard, MB, FRCP, Lyn Title: Emeritus Professor of Medicine
    Date: 11/30/2005
    Comment:

    Dear Dr. McClellan:

    This letter is in response to the Medicare news release about coverage for bariatric surgery procedures.

    For the past 30 years I have been involved with the medical management of morbidly obese patients before and after bariatric surgery. It is very clear that this radical approach is effective and rational only in a small percentage of patients with grade IV & III obesity. Even in these categories patients should be excluded if they have a history of poor medical

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    Krugh, Missy Title: Weight Management Administrator
    Organization: Wilson Memorial Hospital
    Date: 11/30/2005
    Comment:

    WOW.... I am so disappointed! Some of these comments are obviously coming from uneducated and uninformed individuals. How can anybody want to deny a person the opportunity to improve the quality of there live and have the chance to see there children and grandchildren grow? I am an exercise physiologist and have never had a weight issue, but for those who struggle with morbid obesity day in and day out, my heart aches for you. Why not allow an individual to make an informed decision? I have

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    Kuwada, Timothy Date: 11/30/2005
    Comment:

    I am a bariatric/general surgeon. I completed a fellowship in laparoscopy and bariatrics and performed 170 Lap RYGB in my fellowship. However, in my first year of practice I have done
    less than 50 cases.

    I am opposed to the following CMS criteria:

    1) Volume criteria. There are many fellowship trained bariatric surgeons who are well trained in the procedure, however, it can take several years to establish a moderate-high volume program. Limiting coverage to surgeons with more

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    Babineau, Hugh Date: 11/29/2005
    Comment:

    I am a bariatric surgeon who has performed over 1000 bariatric surgeries. I have done dozens of gastric bypasses on people 65 years or older. Because of Medicare's poor reimbursement, I do not perform these surgeries for profit. I do it because it helps these people. My results in patients over 65 have been excellent, with very low complications and no mortalities. It is unfortunate that CMS wants to discontinue coverage for these patients based on ONE study(Flum et. al.). Other studies

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    Huffman, Kevin Date: 11/29/2005
    Comment:

    Cardiac 'centers of excellence' offers cardiac patients both medical and surgical therapy solutions. Bariatric 'centers of excellence' offer only surgical solutions. Should it come as any surprise that every patient who enters a bariatric 'center of excellence' has surgery?

    This one solution fits all approach is not a solution at all. What we are telling overweight patients is that we will offer them care only if they reach 100 pounds of excessive weight and develop comorbid conditions.

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    Sosa, Jorge Title: Medical Doctor
    Organization: New Life Health & Fitness
    Date: 11/29/2005
    Comment:

    There clearly should be coverage for medicare patients less than 65 years old. These often are patients that are disabled due to their obesity and often can be gainfully employed after weight loss surgery. This expanded tax base should be an incentive to offer coverage.

    Making morbidly obese patients prove once again that they cannot control their weight problem before they can undergo definitive treatment with weight loss surgery is needlessly delaying their treatment.

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    Quinn, Bruce Title: medical director
    Organization: nhic (CA part B)
    Date: 11/29/2005
    Comment:

    California Medicare Part B (NHIC) revised its Bariatric Surgery LCD in 2005. We did not consider restrictions over age 65 because (a) most beneficiaries were under 65 and (b) we were unaware of much precedent for cutting off services by age (e.g. implantable cardiac defibrillators over 80,etc) as evidence becomes more thin. We felt that higher risks in older patients should raise the bar for very careful consideration of risks/benefits but it is difficult to regulate every nuance of such

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    Carter, Richard Date: 11/29/2005
    Comment:

    CMS: I have performed over 1000 Lap-Bands. Many have been over age 65-many in an outpt. setting. Complications about 1-2%with NO MORTALITY. I strongly recommend the Lap-Band for those over 65-their lives are changed forever in a very positive,healthy way. Many grandfathers and grandmothers want to enjoy their grandchildren and be active. These memories are all we have in the aging process-and to deny this would be a travesty. Thank you, Richard A. Carter D.O.,FACOS

    Bertha, Nicholas Title: Surgeon
    Organization: Advanced Laparoscopic Surgeons of Morris, LLC
    Date: 11/29/2005
    Comment:

    I think this is a very short sighted decision. The benefits of obesity care in the over 65 aged population have been documented in the literature by Quebbemann et al. and are known to me personally through experiences in my own practice. There is NO QUESTION that obesity treatment RADICALLY changes medical issues for this group and improves quality of life. I can understand the decision of private- for profit- insureres denying coverage based on greed. How can medicare ignore the data? It

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    Dallal, Ramsey Title: Chief, Bariatric Surgery Program
    Organization: Albert Einstien Medical Center
    Date: 11/29/2005
    Comment:

    As the senior author on the only published paper regarding patients greater than 65 undergoing bariatric surgery, I would like to offer my insight.

    We established that in expert hands (fellowship trained surgeons, or surgeons who have performed a significant number of operations) that the morbidity and mortality of bariatric surgery is no different in patients greater than 65 relative to the younger patients. The study by Dr Flum includes many surgeons whose experience is less than

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    Leitman, I. Michael Title: Vice Chairman - Department of Surgery
    Organization: Beth Israel Medical Center
    Date: 11/29/2005
    Comment:

    This is reasonable in light of the most recent Medicare data.

    Kent, Harold Date: 11/29/2005
    Comment:

    Based on Department of Labor Statistics on Consumer Expenditures in 2001, the annual average cost of being obese was over $15,000 per patient. Medication costs, out of pocket health care expenses, and co-pays for medication are about half of this figure. If we expect that patients will require surgical procedures for the co-morbid conditions of obesity including gastroesophageal reflux disease, arthritis with need for total joint replacement, urinary incontinence and others all of which

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    Delagrange, Susan Date: 11/29/2005
    Comment:

    As a Registered Dietitian, I am very disappointed that Medicare is even considering approving bariatric surgery for pt. under 65. The health risks associated with the surgery are tremendous, not to mention the procedure is extremenly expensive. I counsel pt. everyday on how to lose wt. I have people that have lost over 100 pounds and significantly improved their health and have been able to eliminate serveral of the medications they were on. I give them the tools and the support and

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    Ponce, Jaime Date: 11/29/2005
    Comment:

    The credentialing guidelines suggested to approve centers and surgeons to perform bariatric surgery are very well established by the ASBS-SRC Centers of Excellence and Medicare should use this as their accrediting body. The SRC is well underway, establishing centers of excellence, with more than 1000 applicants, site vists, and a well established review committee of well-recognized bariatric surgeons. Creating a different body, will just duplicate work, expenses, and paperwork for

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    Grover, Kathleen Title: none
    Organization: none
    Date: 11/29/2005
    Comment:

    No doubt there are risks associated with bariatric surgery after age 65. However, obesity after age 65 is pretty much a 100% death sentence. To deny life-saving bariatric treatment because "there are risks" condemns many people to death at the hand of Medicare. The decision to weigh a person's relative risk from bariatric surgery should rest in the hands of that person and their doctor alone.

    Baggs, Aaron Title: md
    Date: 11/28/2005
    Comment:

    I speak only for myself. I have been involved with bariatric surgery for the last 5 years. I have seen many patients over the age of 65 present with unrealistic expectations and poor outcomes. While a few may benefit from Gastric Bypass the majority have no significant benefit and they are all at increased risk of mortality. I agree with the age-limited coverage as a broad representation of overall poor physical status as a patient.I also agree with the limitation on BPD and DS. We have

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    Sugerman, Harvey Title: Immediate Past President/President
    Organization: American Society for Bariatric Surgery
    Date: 11/28/2005
    Comment:

    This new National Coverage Determination (NCD) is a major improvement for the care of the morbidly obese Medicare patient. Prior to this, the availability of the surgery varied from region to region and the provider could not be assured of reimbursement until after the procedure was performed and the charges submitted.

    The American Society for Bariatric Surgery (ASBS),who requested this NCD, agrees with CMS thatMedicare patients should undergo their surgery athigh quality surgical

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    Meyer, Kathleen Title: Clinical Supervisor
    Organization: SSM Home Care
    Date: 11/28/2005
    Comment:

    I agree with the coverage of treatment for morbid obesity. I have been a nurse for more than 20 years and the number of co-morbidities exacerbated by the obesity is huge. It would be much more cost effective to treat the obesity than the continual exacerbations of the other health problems caused by the obesity

    Abraham, MD, Jennifer Title: Staff physician
    Organization: Kern Medical Center
    Date: 11/28/2005
    Comment:

    If Medicare will no longer cover bariatric surgery, there should then be coverage for medical care of obesity. The reason the surgery has numbers have increased is that most insurers do not cover anything BUT the surgery for the care of the morbidly obese.

    Abbs, Steve Title: Consultant
    Organization: Donlon & Associates, Inc.
    Date: 11/28/2005
    Comment:

    First, I feel that the criteria that a patient needs to meet in order to be covered for bariatric surgery under Medicare should be stricter, especially for the elderly. Surgical risks increase with age, and surgery such as bariatric surgery should only be performed on extreme cases.

    Specifically, based on my experience as an actuarial health consultant and co-author of a research report regarding the costs and benefits of obesity and bariatric surgery, I feel that a person should

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    Esorami, Iris Date: 11/26/2005
    Comment:

    I think the Lap Band procedure (Adjustable Gastric Banding) should be considered for weight loss surgeries, since they are safer for older people, high success rate, and much cheaper. Less recovery time since it is laproscopic.(sp) This can be life saving for lots of people that can't afford it otherwise.

    Morris, Marjorie Date: 11/24/2005
    Comment:

    I do not believe this surgery benefit should be allowed under Medicare to anyone unless they are physically unable to diet and exercise. Morbid obesity is a personal responsibility, and should not be paid for by taxpayers.

    However, senior citizens eligible for Medicare should NOT be denied bariatric surgery coverage just because of their age. This is discriminatory to people over 65 years of age. Although the risks may be higher to some in this age group, the surgery should not

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    Fleischer, Ron Date: 11/24/2005
    Comment:

    I am not morbidly obese, nor am I elderly...yet. But I object to the idea of denying bariatric coverage to anyone based solely on their age. If they are at immediate risk of death during surgery due to known medical issues, it is the patient and physician's call whether to operate. Just because someone might die within a year does not seem a valid reason for denial. It seems to me that for the morbidly obese a bariatric procedure is a life-saving, life-extending surgery, regardless of

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    Flum, David Date: 11/23/2005
    Comment:

    Our study in JAMA reporting mortality rates in Medicare beneficiaries was cited in CMS' decision to not cover bariatric surgery in patients 65 and older. That study also revealed that surgeons with higher levels of experience were able to provide similar outcomes in young and older Medicare beneficiaries. Given that the increased risk of the procedure among older patients seems to be the reason for the NCD it only seems appropriate that these procedures are covered in older patients when

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    SIMS, ROBERT Date: 11/23/2005
    Comment:

    I see no reason that the taxpayer should pay for obesity surgery when the obesity was brought on by the eating habits and lack of discipline of those seeking to recover the cost of the surgery.