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National Coverage Determination (NCD)

Bariatric Surgery for Treatment of Morbid Obesity

100.1

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Tracking Information

Publication Number
100-3
Manual Section Number
100.1
Manual Section Title
Bariatric Surgery for Treatment of Morbid Obesity
Version Number
2
Effective Date of this Version
02/21/2006
Ending Effective Date of this Version
02/12/2009
Implementation Date
05/30/2006
Implementation QR Modifier Date

Description Information

Benefit Category
Incident to a physician's professional Service
Inpatient Hospital Services
Physicians' Services


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

A. General

Bariatric surgery procedures are performed to treat comorbid conditions associated with morbid obesity. Two types of surgical procedures are employed. Malabsorptive procedures divert food from the stomach to a lower part of the digestive tract where the normal mixing of digestive fluids and absorption of nutrients cannot occur. Restrictive procedures restrict the size of the stomach and decrease intake. Surgery can combine both types of procedures.

The following are descriptions of bariatric surgery procedures:

a. Roux-en-Y Gastric Bypass (RYGBP)

The RYGBP achieves weight loss by gastric restriction and malabsorption. Reduction of the stomach to a small gastric pouch (30 cc) results in feelings of satiety following even small meals. This small pouch is connected to a segment of the jejunum, bypassing the duodenum and very proximal small intestine, thereby reducing absorption. RYGBP procedures can be open or laparoscopic.

b. Biliopancreatic Diversion with Duodenal Switch (BPD/DS)

BPD achieves weight loss by gastric restriction and malabsorption. The stomach is partially resected, but the remaining capacity is generous compared to that achieved with RYGBP. As such, patients eat relatively normal-sized meals and do not need to restrict intake radically, since the most proximal areas of the small intestine (i.e., the duodenum and jejunum) are bypassed, and substantial malabsorption occurs. The partial BPD with duodenal switch is a variant of the BPD procedure. It involves resection of the greater curvature of the stomach, preservation of the pyloric sphincter, and transection of the duodenum above the ampulla of Vater with a duodeno-ileal anastamosis and a lower ileo-ileal anastamosis. BPD/DS procedures can be open or laparoscopic.

c. Adjustable Gastric Banding (AGB)

AGB achieves weight loss by gastric restriction only. A band creating a gastric pouch with a capacity of approximately 15 to 30 cc’s encircles the uppermost portion of the stomach. The band is an inflatable doughnut-shaped balloon, the diameter of which can be adjusted in the clinic by adding or removing saline via a port that is positioned beneath the skin. The bands are adjustable, allowing the size of the gastric outlet to be modified as needed, depending on the rate of a patient’s weight loss. ABG procedures are laparoscopic only.

d. Sleeve Gastrectomy

Sleeve gastrectomy is a 70%-80% greater curvature gastrectomy (sleeve resection of the stomach) with continuity of the gastric lesser curve being maintained while simultaneously reducing stomach volume. It may be the first step in a two-stage procedure when performing RYGBP. Sleeve gastrectomy procedures can be open or laparoscopic.

e. Vertical Gastric Banding (VGB)

VBG achieves weight loss by gastric restriction only. The upper part of the stomach is stapled, creating a narrow gastric inlet or pouch that remains connected with the remainder of the stomach. In addition, a non-adjustable band is placed around this new inlet in an attempt to prevent future enlargement of the stoma (opening). As a result, patients experience a sense of fullness after eating small meals. Weight loss from this procedure results entirely from eating less.
Indications and Limitations of Coverage

B. Nationally Covered Indications

Open and laparoscopic Roux-en-Y gastric bypass (RYGBP), open and laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS), and laparoscopic adjustable gastric banding (LAGB) are covered for Medicare beneficiaries who have a body-mass index ≥ 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. These procedures are only covered when performed at facilities that are: (1) certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center (program standards and requirements in effect on February 15, 2006); or (2) certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (program standards and requirements in effect on February 15, 2006).

A list of approved facilities and their approval dates are listed and maintained on the CMS Coverage Web site at http://www.cms.hhs.gov/center/coverage.asp, and published in the Federal Register.

C. Nationally Non-covered Indications

The following bariatric surgery procedures are non-covered for all Medicare beneficiaries:

  • Open adjustable gastric banding
  • Open and laparoscopic sleeve gastrectomy; and
  • Open and laparoscopic vertical banded gastroplasty.

The two previously non-coverage determinations remain unchanged - Gastric Balloon (Section 100.11) and Intestinal Bypass (Section 100.8).

D. Other

(This NCD last reviewed February 2006.)
Cross Reference

See §§40.5, 100.8, and 100.11.
Claims Processing Instructions

Transmittal Information

Transmittal Number
54
Coverage Transmittal Link
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R54NCD.pdf
Revision History

04/2006 - Medicare will cover open and laparoscopic Roux-en Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB) and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) if certain criteria are met and the procedure is performed in an approved facility. Effective date: 02/21/2006 (TN 54) (CR5013).

Implementation Dates:

  • 05/30/2006 for physician claims billed to the carrier
  • 10/02/2006 for hospital claims billed to the FI
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity 5 09/24/2013 - N/A View
Bariatric Surgery for Treatment of Morbid Obesity 4 06/27/2012 - 09/24/2013 View
Bariatric Surgery for Treatment of Morbid Obesity 3 02/12/2009 - 06/27/2012 View
Bariatric Surgery for Treatment of Morbid Obesity 2 02/21/2006 - 02/12/2009 You are here
Gastric Bypass Surgery for Obesity 1 10/01/1979 - 02/21/2006 View
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Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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