LCD/NCD Portal

NCD100.14

 

SURGERY FOR DIABETES

 

 

Effective Date of this Version

5/18/2009

 

Benefit Category

• Physicians' Services.

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

 

Item/Service Description

A. General

• Medicare currently covers bariatric surgery for persons with type 2 diabetes mellitus (T2DM) and a body mass index (BMI) > 35.

• Surgical procedures that are used in this context are discussed in section 100.1.

• It was proposed that these same procedures may be beneficial for beneficiaries with T2DM who do not meet the criteria for treatment of morbid obesity.

• The Centers for Medicare & Medicaid Services (CMS) specifically evaluated the evidence associated with surgery among persons with T2DM to assess the effectiveness of such procedures in reducing the signs and symptoms of this disease in Medicare beneficiaries with a BMI < 35.

 

Indications and Limitations of Coverage

B. 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 have a BMI ≥ 35, have at least one co-morbidity related to obesity, and 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).

 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 and after February 12, 2009, CMS determines that T2DM is a co-morbidity for purposes of section 100.1.

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

 

Nationally Non-Covered Indications

• Effective for services performed on and after February 12, 2009:

o Open and laparoscopic RYGBP.

o Open and laparoscopic BPD/DS.

o LAGB.

• Are NON-COVERED for Medicare beneficiaries who have a BMI < 35 and T2DM.

 

Other

• N/A

• (This NCD last reviewed February 2009.)

 

Claims Processing Instructions

• TN 1728 (Medicare Claims Processing)

 

Coverage Transmittal Link

• http://www.cms.gov/transmittals/downloads/R100NCD.pdf

 

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.

• Original consideration for Surgery for Diabetes (CAG-00397N) opens in new window

 

 

Medicare NCD Link