LCD/NCD Portal

NCD100.1

 

BARIATRIC SURGERY FOR TREATMENT OF MORBID OBESITY

 

 

Effective Date of this Version

6/27/2012

 

Item/Service Description

General

 

Indications and Limitations of Coverage

 

Nationally Covered Indications

• Effective for services performed on and after February 21, 2006, 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:

o Have a body-mass index > 35.

o Have at least one co-morbidity related to obesity.

And

o Have been previously unsuccessful with medical treatment for obesity.

o These procedures are only covered when performed at facilities that are:

 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).

• Effective for services performed on or after February 12, 2009, the Centers for Medicare & Medicaid Services (CMS) determine that Type 2 diabetes mellitus is a co-morbidity for purposes of this NCD.

• A list of approved facilities and their approval dates are listed and maintained on the CMS Coverage Web site at http://www.cms.gov/Medicare/Medicare-General-Information/MedicareApprovedFacilitie/Bariatric-Surgery.html, and published in the Federal Register.

 

Nationally Non-Covered Indications

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

o Open adjustable gastric banding.

o Open and laparoscopic sleeve gastrectomy.

o Open and laparoscopic vertical banded gastroplasty.

• The two previous non-coverage determinations remain unchanged:

o Gastric Balloon (Section 100.11)

o Intestinal Bypass (Section 100.8)

 

Claims Processing Instructions

• TN 1728 (Medicare Claims Processing) (Will need to download for coding)

• TN 2590 (Medicare Claims Processing) (Will need to download for coding)

 

Treatment Logic

• 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:

• Roux-en-Y Gastric Bypass (RYGBP)

o The RYGBP achieves weight loss by gastric restriction and malabsorption.

o Reduction of the stomach to a small gastric pouch (30 cc) results in feelings of satiety following even small meals.

o This small pouch is connected to a segment of the jejunum, bypassing the duodenum and very proximal small intestine, thereby reducing absorption.

o RYGBP procedures can be open or laparoscopic.

• Biliopancreatic Diversion with Duodenal Switch (BPD/DS)

o BPD achieves weight loss by gastric restriction and malabsorption.

o The stomach is partially resected, but the remaining capacity is generous compared to that achieved with RYGBP.

o 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.

o The partial BPD/DS is a variant of the BPD procedure.

o 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.

o BPD/DS procedures can be open or laparoscopic.

• Adjustable Gastric Banding (AGB)

o AGB achieves weight loss by gastric restriction only.

o A band creating a gastric pouch with a capacity of approximately 15 to 30 cc’s encircles the uppermost portion of the stomach.

o 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.

o 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. AGB procedures are laparoscopic only.

• Sleeve Gastrectomy

o 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.

o It may be the first step in a two-stage procedure when performing RYGBP. Sleeve gastrectomy procedures can be open or laparoscopic.

• Vertical Gastric Banding (VGB)

o The VGB achieves weight loss by gastric restriction only.

o The upper part of the stomach is stapled, creating a narrow gastric inlet or pouch that remains connected with the remainder of the stomach.

o In addition, a non-adjustable band is placed around this new inlet in an attempt to prevent future enlargement of the stoma (opening).

o As a result, patients experience a sense of fullness after eating small meals.

o Weight loss from this procedure results entirely from eating less.

o VGB procedures are essentially no longer performed.

 

 

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