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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 given the strengths and limitations of the evidence, Palmetto GBA will cover laparoscopic 
sleeve gastrectomy (LSG) only when ALL of the following criteria are met: 
 Patient has a BMI greater than or equal to 35.0 kg/m2 (Class II or Class III obesity) 
 Patient has at least 1 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 6 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 
 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, 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 1 of the following serious comorbidities: 
 Diabetes Mellitus    
 Hypertension not well controlled with a single medication    
 Hyperlipidemia requiring more than 1 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 United Network for Organ Sharing (UNOS)-certified 
center whereby a BMI greater than or equal to 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 for Laparoscopic Sleeve Gastrectomy for Severe Obesity, 
L34576.  
 
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.