Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
The rules say that Palmetto GBA is concerned that there are no randomized controlled trials (RCTs) that 
specifically evaluated adults greater than or equal to 61 years, few large scale trials on stand-alone LSG and 
few, if any, long term trials. Palmetto GBA medical directors have also discussed the surgery with subject 
matter experts in our jurisdiction. Given the strengths and limitations of the evidence, Palmetto GBA will cover 
laparoscopic sleeve gastrectomy only when ALL of the following criteria are met: 
- Patient has a BMI; 35.0 kg/m (Class II or Class III obesity) 
- Patient has at least one co-morbidity related to obesity, and, 
- Active participation within the last 12 months prior to bariatric surgery in a weight-management 
program that is supervised by a physician or other health care professionals. The weight-management 
program must include monthly documentation of ALL of the following components:  
- weight 
- current dietary regimen 
- physical activity (e.g., exercise program) 
Physician-supervised programs consisting exclusively of pharmacological management are not sufficient to 
meet this requirement. 
- A thorough multidisciplinary evaluation within the previous six months which includes ALL of the 
following:  
- an evaluation by a bariatric surgeon recommending surgical treatment, including a description of 
the proposed procedure(s) 
- a primary care provider referral 
- evaluation for bariatric surgery by a mental health provider including a statement regarding 
motivation and ability to follow post-surgical requirements 
o a nutritional evaluation by a physician or registered dietician 
- For dates of service prior to September 24, 2013, LSG shall be furnished in a CMS approved bariatric 
facility. 
- For dates of service on or after September 24, 2013 facility certification shall no longer be required for 
coverage of covered bariatric procedures. 
- For a patient with age greater than 61 years: In recognition of both the need to provide obesity 
treatment and the potential for increased risk and decreased benefit in older patients, Palmetto will 
cover laparoscopic sleeve gastrectomy if, in addition to the criteria established above, the following are 
met: 
1. In addition to the nutritional and psychological evaluation previously outlined in this local coverage 
determination (LCD), there must be evidence documented in the patient's medical record that the patient is able 
to personally understand the nature and potential complications of surgery and has the capacity to follow the 
postoperative care and nutritional requirements, and the patient must sign the informed consent personally. 
 
2. Indications for surgery in this age group will include at least one of the following serious comorbidities: 
 
 
-  
- Diabetes Mellitus    
- Hypertension not well controlled with a single medication    
- Hyperlipidemia requiring more than one medication to manage    
- Joint Disease requiring surgical intervention  
- Gastroesophageal Reflux Disease (GERD) refractory to a 2 month trial of appropriate treatment 
and medications,    
- Obstructive Sleep Apnea requiring CPAP, OR 
- Potential organ transplant candidacy at a UNOS-certified center whereby a BMI &#8805; 35 is 
required. 
3. Contraindications include: 
-  
- Dementia to the extent that self-care is precluded (including exercise and nutritional care) 
- Requirement for Home Oxygen therapy 
- Organ failure unless the patient is a transplant candidate to replace the failing organ at an UNOS 
certified-center. 
The information above must be documented in the patient's medical record and available on request. 
You can find this rule in the Local Coverage Determination (LCD): Laparoscopic Sleeve Gastrectomy for 
Severe Obesity (L34576) effective October 10,2 019. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.