Medicare has expanded its coverage of bariatric surgery to its beneficiaries of all ages—provided that those patients seek care in facilities certified by the American College of Surgeons or the American Society for Bariatric Surgery.
The Centers for Medicare and Medicaid Services had originally proposed to exclude patients aged 65 years and older from coverage for bariatric surgery, based on the significant surgical risks seen in studies of this population.
But in reviewing new data and analyses, the agency determined that similar outcomes could be obtained in patients of all ages—provided that the surgery be performed in facilities capable of handling large numbers of these procedures and that it be performed only by highly qualified surgeons.
In its national coverage decision, CMS said it had evaluated the certification programs of the American College of Surgeons and the American Society for Bariatric Surgery and determined that facilities deemed Centers of Excellence by either organization would be able to produce the best surgical results.
The ACS devised its standards “for anybody performing this surgery in adults of any age,” Dr. R. Scott Jones, the ACS's director of the division of research and optimal patient care, said in an interview. “We've got a big problem with obesity, so it's important for the public to know that they can go to a hospital that meets standards that are subject to scrutiny.”
In announcing the national coverage decision, CMS Administrator Dr. Mark B. McClellan said, “Bariatric surgery is not the first option for obesity treatment, but when performed by expert surgeons, it is an important option for some of our beneficiaries.
“While we want to see more evidence on the benefits and risks of this procedure, some centers have demonstrated high success rates, and we want to ensure access to the most up-to-date treatment alternatives for our beneficiaries.”
CMS's original proposal, issued late last year, would have excluded coverage for patients older than 65 years, except in clinical trials.
Evidence regarding the benefits of the surgery is more limited for the over-65 population, Cynthia A. Brown, director of advocacy and health policy at ACS, said in an interview.
Nevertheless, she noted “the procedure is valuable, and ought to be covered as part of the process that includes data collection and quality monitoring. And that's what CMS is doing.”
The College started its certification program “because of concerns on what happens when new technology gets disseminated into the community and used in specialized facilities,” Ms. Brown said.
“Our certification program addresses those issues, as well as data collection, to monitor outcomes.”
The national coverage decision also expands the types of bariatric procedures Medicare covers for its beneficiaries. Previously, only gastric bypass surgery was covered; now the list also includes open or laparoscopic Roux-en-Y bypass, laparoscopic adjustable gastric banding, and open or laparoscopic biliopancreatic diversion with duodenal switch.
Although Medicare's bariatric coverage has expanded regarding patient age and types of procedures, limitations do remain. Coverage is still restricted to obese patients who have one or more comorbidities, such as hypertension, type 2 diabetes, osteoarthritis, or coronary heart disease, according to CMS.
More information on the American College of Surgeons' bariatric surgery certification program is available at www.facs.org/cqi/bscn/index.htmlwww.cms.hhs.gov/center/coverage.asp