The Centers for Medicare & Medicaid Services (CMS) has clarified its policy for Medicare coverage of bariatric surgery as a treatment for certain beneficiaries with type-2 (or non-insulin-dependent) diabetes.
The agency said that its decision specifies type-2 diabetes for bariatric surgery coverage only for a morbidly obese beneficiary, as long as the surgery is furnished at a CMS-approved facility. An individual with a body-mass index (BMI) of at least 35 is considered morbidly obese. Normal body-mass index is considered to be between 18.5 and 25.
"Medicare beneficiaries who are morbidly obese may face tremendous health complications," said CMS Acting Administrator Charlene Frizzera. "Today's coverage decision assures that beneficiaries who are morbidly obese can access safe, effective weight loss options to help prevent these complications."
As part of the decision, CMS said that bariatric surgery will not be covered by Medicare when it is used to treat type-2 diabetes in a beneficiary with a BMI below 35. While recent medical reports claimed that bariatric surgery may be helpful for these patients, CMS said it "did not find convincing medical evidence that bariatric surgery improved health outcomes for these non-morbidly obese individuals."
"Limiting coverage of bariatric surgery in type-2 diabetic patients who are not considered clinically obese is part of Medicare's ongoing commitment to ensure access to the most effective treatment alternatives with good evidence of benefit, while limiting coverage where the current evidence suggests the risks outweigh the benefits," said Barry Straube, MD, CMS chief medical officer and director of the agency's Office of Clinical Standards & Quality.
In 2006, CMS expanded coverage of bariatric surgery for Medicare beneficiaries who received surgery in high-volume centers from highly qualified surgeons. Under that decision, to be considered for coverage, Medicare beneficiaries were required to have a BMI of 35 or higher, and to have exhibited a serious health condition in addition to morbid obesity, such as hypertension and coronary artery disease.