Medicare Coverage Updates December 2012

on Monday, 10 December 2012. All News Items | Medicare Coverage


This month we would like to highlight the National Coverage Determination for Bariatric Surgery for Treatment of Morbid Obesity (NCD 100.1). The original NCD for bariatric surgery was approved in February 2006 and bariatric surgery is covered by Medicare as indicated below.
Approved Types of Bariatric Surgeries:
  • 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)
Medical conditions/criteria necessary for coverage:
  • A body-mass index (BMI) ? 35 kg/m2,
  • At least one co-morbidity related to obesity (effective February 2009, Type 2 diabetes mellitus is a co-morbidity for purposes of this NCD), and,
  • Previously unsuccessful medical treatment for obesity.

When performed at facilities that are:
  • certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center; or
  • certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence.
The following bariatric surgery procedures are non-covered for all Medicare beneficiaries:
  • Open adjustable gastric banding;
  • Open sleeve gastrectomy; and,
  • Laparoscopic sleeve gastrectomy (prior to June 27, 2012)
  • Open and laparoscopic vertical banded gastroplasty.

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 conditions listed above (a-c) are met.
Cahaba GBA (Jurisdiction 10 MAC) will cover LSG for the conditions listed when performed in a certified facility – see Article A48897. Palmetto GBA (Jurisdiction 11 MAC) currently considers LSG non-covered. Palmetto has a draft LCD (DL32975) that will allow coverage of LSG, but only for patients less than 65 years of age and who meet other requirements. Novitas has not addressed the coverage of LSG at this time.
 
New and Revised Coverage Documents for December include:
ServiceMACTypePolicy #ChangeCommentsEffective
Bariatric Surgery for the Treatment of Morbid Obesity   NCD 100.1 revised MM8028 6/27/2012
Radiology: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) Cahaba (J10) LCD DL32973 draft comment period: 11/16/12 – 12/31/12 11/16/2012
Surgery: Major Joint Replacement (Hip and Knee) Cahaba (J10) LCD DL32971 draft comment period: 11/16/12 – 12/31/12 11/16/2012
Approved Drugs and Biologicals; Includes Cancer Chemotherapeutic Agents Novitas (J12) LCD A47797 revised additional guidance regarding drugs infused through an implantable infusion pump 11/16/2012
In Vitro Chemosensitivity @ Chemoresistance Assays Novitas (J12) LCD L32571 on hold previously finalized to be effective 11/15/2012 11/15/2012
Respiratory Therapy (Respiratory Care) Palmetto (J11) LCD L31593 revised minor revisions 11/1/2012
Outpatient Speech Language Pathology Palmetto (J11) LCD L31603 revised new covered diagnosis and other changes 11/1/2012
Cardiac Event Detection Palmetto (J11) LCD L31595 revised minor revisions 11/1/2012
Polices and articles can be viewed on the Medicare Coverage Database by entering the policy number in the Document ID search.
 
Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it. .

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