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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 the surgical management for the treatment of morbid obesity is considered reasonable and necessary for all nationally covered bariatric surgical procedures and Laproscopic sleeve gastrectomy when ALL of the following conditions are met and recorded in the medical record:
- The patient meets the definition of morbid obesity which is defined as a body mass index (BMI) greater than 35 and comorbid conditions exist (e.g., hypertensive cardiovascular disease, pulmonary/respiratory disease, diabetes, sleep apnea or degenerative arthritis of weight-bearing joints). Documentation of the level of severity of the comorbid existing condition must be included in the patient's medical record; AND
- The patient has been previously unsuccessful with medical treatment for obesity; AND
- Treatable metabolic causes for obesity (e.g., adrenal or thyroid disorders) have been ruled out or have been clinically treated if present.
Unsuccessful Medical Treatment for Obesity
With or without bariatric surgery, successful obesity management requires adoption and lifelong practice of healthy eating and physical exercise (i.e. lifestyle modification) by the obese patient. Without adequate patient motivation and/or skills needed to make such lifestyle modifications, the benefit of bariatric surgical procedures is severely jeopardized and not medically reasonable or necessary. Patients considering bariatric surgical options must have been provided with knowledge and tools needed to achieve such lifelong lifestyle changes and must be capable and willing to undergo the changes.
For the purposes of this LCD, a patient will be deemed to have been unsuccessful with medical treatment of obesity if all of the following minimal requirements are met per documentation in the medical record:
- The patient has BMI greater than or equal to 35 at the time of surgery.
- The patient has been provided with knowledge and tools needed to achieve such lifelong lifestyle changes, exhibits understanding of the needed changes and has demonstrated to clinicians involved in his or her care to be capable and willing to undergo the changes.
- The patient has made a diligent effort to achieve healthy body weight with such efforts described in the medical record and certified by the operating surgeon.
- The patient has failed to maintain a healthy weight despite adequate participation in a structured dietary program overseen by one of the following:
o Physician (MD or DO).
o Registered dietician (RD).
o Board certified specialist in pediatric nutrition (CSP).
o Board certified specialist in renal nutrition (CSR).
o Fellow of the American Dietetic Association (FADA).
Preoperative Psychological/Psychiatric Evaluation
Patients who have a history of psychiatric or psychological disorder or are currently under the care of a psychologist/psychiatrist, or are on psychotropic medications, must undergo preoperative psychological evaluation and clearance and the patient's record must include documentation of the evaluation and assessment.
An objective examination by a mental health professional (psychiatrist or psychologist) experienced in the evaluation and management of bariatric surgery candidates to exclude patients who are unable to personally provide informed consent, who are unable to comply with a reasonable pre- and postoperative regimen, or who have a significant risk of postoperative decompensation is recommended. Such evaluation is a covered service. A diagnostic session is appropriate, and treatment sessions are appropriate if the patient has a diagnosable disorder that is likely to adversely impact the surgical outcome including post -operative compliance. The mental health professional, the surgeon and the patient should be in agreement that the patient is an appropriate candidate for the surgery.
Comorbid Conditions
Severe obesity (BMI) greater than or equal to 35 kg/m2 is known to exacerbate numerous medical conditions. Comorbid conditions for which bariatric surgery is covered include the following:
- Type II diabetes mellitus (by American Diabetes Association diagnostic criteria).
- Resistant hypertension (defined as blood pressure of 140 mmHg systolic and/or 90 mmHg diastolic despite medical treatment with maximal doses of three antihypertensive medications).
- Refractory hyperlipidemia (acceptable levels of lipids unachievable with diet and maximum doses of lipid lowering medications).
- Obesity-induced cardiomyopathy.
- Clinically significant obstructive sleep apnea.
- Obesity-related hypoventilation.
- Pseudotumor cerebri (documented idiopathic intracerebral hypertension).
- Severe arthropathy of spine and/or weight-bearing joints (when obesity prohibits appropriate surgical management of joint dysfunction treatable but for the obesity).
- Nonalcoholic fatty liver disease (NAFLD) as confirmed by physician with expertise in liver disease. Consideration of the risk-benefit for each individual patient must be used to determine that surgery for obesity is the best option for treatment for that patient and no contraindications to bariatric surgery may exist.
You can find this rule in the Local Coverage Determination (LCD): Surgical Management of Morbid Obesity (L33411) effective October 1, 2019.
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.