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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, Medicare will cover laparoscopic sleeve gastrectomy (LSG) only when ALL of the following criteria are met:

1. Patient has a BMI &#8805; 35.0 kg/m? (Class II or Class III obesity) 
2. Patient has at least 1 co-morbidity related to obesity, and, 
3. 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: 

a. weight 
b. current dietary regimen 
c. physical activity (e.g. exercise program) 

4. A thorough multidisciplinary evaluation within the previous 6 months which includes ALL of the following: 

a. an evaluation by a bariatric surgeon recommending surgical treatment, including a description of the proposed procedure(s) 
b. a primary care provider referral 
c. evaluation for bariatric surgery by a mental health provider including a statement regarding motivation and ability to follow post-surgical requirements 
d. a nutritional evaluation by a physician or registered dietician 

5. For dates of service prior to September 24, 2013, LSG shall be furnished in a CMS approved bariatric facility. 
6. For dates of service on or after September 24, 2013 facility certification shall no longer be required for coverage of covered bariatric procedures. 

You can find this rule in the Local Coverage Determination (LCD) - Laparoscopic Sleeve Gastrectomy for Severe Obesity (L34576) - Effective December 10, 2020. 

The rules say that physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet the requirement for a weight-management program. You can find this rule in the Local Coverage Determination (LCD) - Laparoscopic Sleeve Gastrectomy for Severe Obesity (L34576) - Effective December 10, 2020. 

The rules say that in recognition of the need to provide obesity treatment and the potential for increased risk and decreased benefit in older patients (age greater than 61 years), Medicare 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 1 of the following serious comorbidities: 

a. Diabetes Mellitus 
b. Hypertension not well controlled with a single medication 
c. Hyperlipidemia requiring more than 1 medication to manage 
d. Joint Disease requiring surgical intervention 
e. Gastroesophageal Reflux Disease (GERD) refractory to a 2 month trial of appropriate treatment and medications 
f. Obstructive Sleep Apnea requiring CPAP, OR 
g. Potential organ transplant candidacy at a United Network for Organ Sharing (UNOS)-certified center whereby a BMI &#8805; 35 is required.

3. Contraindications include: 

a. Dementia to the extent that self-care is precluded (including exercise and nutritional care) 
b. Requirement for Home Oxygen therapy 
c. Organ failure unless the patient is a transplant candidate to replace the failing organ at an UNOS certified-center. 

You can find this rule in the Local Coverage Determination (LCD) - Laparoscopic Sleeve Gastrectomy for Severe Obesity (L34576) - Effective December 10, 2020.

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.