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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 state that the sleeve gastrectomy (SG) is a surgical procedure performed in either an open or 
laparoscopic manner. The surgery involves excision of the lateral aspect of the stomach, leaving a much 
reduced, tubular stomach. When performed laparoscopically, the term laparoscopic sleeve gastrectomy (LSG) 
is used. Presently, LSG is being used as a stand-alone approach to bariatric surgery. By reducing gastric 
capacity, there is both short- and long-term weight loss. A stand-alone SG is sometimes referred to as an 
isolated SG. There are variations in the detail and technique for the SG procedure itself. LSG has been gaining 
popularity over the last few years with increased experience among surgeons and the procedure has taken its 
place among other bariatric surgical procedures for extreme obesity. Unlike some bariatric surgical procedures, 
this technique is irreversible. 
 
Obesity, defined as a body mass index (BMI) = 30kg/m2, is recognized as an important risk factor for 
morbidity and mortality associated with a number of chronic diseases, such as heart disease and diabetes 
(Flegal, 2010). The Centers for Disease Control and Prevention (CDC) reported that obesity rates in the United 
States have increased dramatically over the last 30 years, and obesity is now epidemic in the United States 
(Kahn, 2009). For adults 60 years and older, the prevalence of obesity is about 37% among men and 34% 
among women (NHANES - National Health and Nutrition Examination Survey). Obesity may be further 
classified according to the National Institutes of Health (NIH): 
 
    Class I Obesity = BMI 30.0-34.9 kg/m2 
    Class II Obesity = BMI 35.0-39.9 kg/m2 
    Class III (Extreme) Obesity = BMI = 40.0 kg/m2 
 
The Centers for Medicare and Medicaid Services (CMS) has recognized the importance of screening and 
treating obesity and recently provided Medicare coverage for intensive behavioral therapy for obesity. CMS 
also has allowed national coverage for some bariatric surgical procedures for Class II and Class III obesity: 
 
    Open and laparoscopic Roux-en-Y gastric bypass (RYGBP) 
    Laparoscopic adjustable gastric banding (LAGB) and 
    Open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) or gastric reduction 
duodenal switch (BPD/GRDS). 
 
LSG was specifically not approved under past National Coverage Determinations (NCDs). Recently, under a 
national coverage analysis (Decision Memo for Bariatric Surgery for the Treatment of Morbid Obesity CAG-00250R2) CMS has made the decision to allow discretion for stand-alone LSG coverage to be at the local 
contractor level. Open SG is specifically not covered in the CMS NCD. 
 
Palmetto GBA is concerned that there are no randomized controlled trials (RCTs) that specifically evaluated 
adults = 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/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) 
 
You can find this information in the Local Coverage Determination (LCD) Laparoscopic Sleeve Gastrectomy 
for Severe Obesity L34576. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.