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 state that severe obesity is known to aggravate numerous medical conditions. Comorbid conditions for which bariatric surgery is covered include the following: A. Type II diabetes mellitus (by American Diabetes Association diagnostic criteria). B. Refractory hypertension (defined as blood pressure of 140 mmHg systolic and/or 90 mmHg diastolic despite medical treatment with maximal doses of three antihypertensive medications). C. Refractory hyperlipidemia (acceptable levels of lipids unachievable with diet and maximum doses of lipid lowering medications). D. Obesity-induced cardiomyopathy. E. Clinically significant obstructive sleep apnea. F. Obesity-related hypoventilation. G. Pseudotumor cerebri (documented idiopathic intracerebral hypertension). H. Severe arthropathy of spine and/or weight-bearing joints (when obesity prohibits appropriate surgical management of joint dysfunction treatable but for the obesity). I. Hepatic steatosis without prior evidence of active inflammation. Though the conditions listed above need not be immediately life-threatening for Medicare to cover bariatric surgery, the condition must not be trivial or easily controlled with non-invasive means (such as medication) and must be of sufficient severity as to pose considerable short- or long-term risk to function and/or survival. 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. Refer to IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 150, for more information on co-morbid conditions related to morbid obesity.  Previous 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: A. The patient meets BMI requirements stated in national policy (at the time of surgery). B. The patient has been provided with knowledge and tools needed to achieve such lifelong lifestyle changes, exhibits understanding of the needed changes and is demonstrated to clinicians involved in his or her care to be capable and willing to undergo the changes. C. 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. D. The patient has failed to maintain a healthy weight despite adequate participation in a structured dietary program overseen by one of the following: a) Physician (MD or DO). b) Registered dietician (RD). c) Board certified specialist in pediatric nutrition (CSP). d) Board certified specialist in renal nutrition (CSR). e) Fellow of the American Dietetic Association (FADA).  Repeat bariatric surgery is generally not reasonable and necessary. Medicare does not provide prior authorization for these services. Claims for more than one bariatric surgical procedure most likely will create a denial. However, in the appeals process, medical documentation may be submitted for review and the service may potentially be covered when clinical circumstances demonstrate reasonability and necessity.   You can find these rules in the Local Coverage Determination (LCD) for Bariatric Surgical Management of Morbid Obesity, L35022.  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.