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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 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) = 30 kilogram (kg)/square meter (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. 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. 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, 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. 
 
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 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, LSG is covered 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: 
 
     *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 continuous positive airway pressure (CPAP), OR 
     * Potential organ transplant candidacy at a United Network for Organ Sharing (UNOS)-certified center 
whereby a BMI = 35 is required. 
 
You can find these rules 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.