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Medicare Releases Proposed New Rules for Weight-Loss Surgery

Winter 2006

As many of you are aware, on November 23, 2005, the Centers for Medicare & Medicaid Services (CMS), the governing agency of Medicare, released proposed new rules under a National Coverage Decision (NCD) for weight-loss surgery.

The OAC strongly believes these proposed rules are a positive change that will improve access to the treatment of morbid obesity. Understanding the rules and regulations proposed under the NCD are important not only for those currently insured by Medicare, but also for those covered by commercial insurance policies, as many insurance companies base their coverage decisions on Medicare’s policies.

The proposed rules validate the treatment of morbid obesity through weight-loss surgery. Surgical treatment options for Medicare recipients, who are under the age of 65, will now include both open and laparoscopic Roux-EN-Y gastric bypass as well as laparoscopic adjustable gastric banding (commonly known as Lap-Band) as long as the patient has a body mass index (BMI) of 35 or greater, one obesity-related health problem and has been previously unsuccessful with the medical treatment of their obesity.

The OAC’s Response

The OAC supports the coverage of weight-loss surgery, as studies show the surgical treatment of morbid obesity decreases mortality, improves or resolves obesity-related illnesses and improves quality of life.

However, the OAC does have specific concerns with portions of the NCD as it proposes eliminating coverage of weight-loss surgery as a benefit for those more than 65 years of age. Other concerns include not specifying or defining the requirement of being unsuccessful with the medical treatment of obesity to access surgery, failure to provide coverage of biliopancreatic diversion with duodenal switch (BPDS) and a lack of information on payment for the required future follow-up physician and healthcare professional visits required for optimal post-operative care.

“We received an overwhelming response of support from our members on this subject, and we greatly appreciate all those who submitted comments to CMS,” said Joseph Nadglowski, Jr., President and CEO.

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