**B. Nationally Covered Indications**

Effective for services performed on and after February 21, 2006, Open and
laparoscopic Roux-en-Y gastric bypass (RYGBP), open and laparoscopic
Biliopancreatic Diversion with Duodenal Switch (BPD/DS) or Gastric Reduction
Duodenal Switch (BPD/GRDS), and laparoscopic adjustable gastric banding (LAGB)
are covered for Medicare beneficiaries who have a body-mass index  35, have
at least one co-morbidity related to obesity, and have been previously
unsuccessful with medical treatment for obesity.

Effective for dates of service on and after February 21, 2006, these
procedures are only covered when performed at facilities that are: (1)
certified by the American College of Surgeons as a Level 1 Bariatric Surgery
Center (program standards and requirements in effect on February 15, 2006); or
(2) certified by the American Society for Bariatric Surgery as a Bariatric
Surgery Center of Excellence (program standards and requirements in effect on
February 15, 2006). Effective for dates of service on and after September 24,
2013, facilities are no longer required to be certified.

Effective for services performed on and after February 12, 2009, the Centers
for Medicare & Medicaid Services (CMS) determines that Type 2 diabetes
mellitus is a co-morbidity for purposes of this NCD.

A list of approved facilities and their approval dates are listed and
maintained on the CMS Coverage Web site at
http://www.cms.gov/Medicare/Medicare-General-
Information/MedicareApprovedFacilitie/Bariatric-Surgery.html, and published in
the Federal Register for services provided up to and including date of service
September 23, 2013.

**C. Nationally Non-Covered Indications**

Treatments for obesity alone remain non-covered.

Supplemented fasting is not covered under the Medicare program as a general
treatment for obesity (see section D. below for discretionary local coverage).

The following bariatric surgery procedures are non-covered for all Medicare
beneficiaries:

Open adjustable gastric banding;

Open sleeve gastrectomy;

Laparoscopic sleeve gastrectomy (prior to June 27, 2012);

Open and laparoscopic vertical banded gastroplasty;

Intestinal bypass surgery; and,

Gastric balloon for treatment of obesity.

**D. Other**

Effective for services performed on and after June 27, 2012, Medicare
Administrative Contractors (MACs) acting within their respective jurisdictions
may determine coverage of stand-alone laparoscopic sleeve gastrectomy (LSG)
for the treatment of co-morbid conditions related to obesity in Medicare
beneficiaries only when all of the following conditions a.-c. are satisfied.

  1. The beneficiary has a body-mass index (BMI)  35 kg/m2, 
  2. The beneficiary has at least one co-morbidity related to obesity, and, 
  3. The beneficiary has been previously unsuccessful with medical treatment for obesity. 

The determination of coverage for any bariatric surgery procedures that are
not specifically identified in an NCD as covered or non-covered, for Medicare
beneficiaries who have a body-mass index  35, have at least one co-morbidity
related to obesity, and have been previously unsuccessful with medical
treatment for obesity, is left to the local MACs.

Where weight loss is necessary before surgery in order to ameliorate the
complications posed by obesity when it coexists with pathological conditions
such as cardiac and respiratory diseases, diabetes, or hypertension (and other
more conservative techniques to achieve this end are not regarded as
appropriate), supplemented fasting with adequate monitoring of the patient is
eligible for coverage on a case-by-case basis or pursuant to a local coverage
determination. The risks associated with the achievement of rapid weight loss
must be carefully balanced against the risk posed by the condition requiring
surgical treatment.