Once upon a time, obesity was a challenge very difficult to overcome.
For so many years, obesity has become one of the biggest factors to have plagued mankind. It brought heart diseases, diabetes, stroke, bone problems and many others that have affected the society at large. In the United States alone, approximately 190 million citizens are affected, the US Department of Health & Human Services reveals.
Many have tried overcoming this burden through exercise and diet. However, not everyone has succeeded. Those who have failed now turn to other options such as bariatric surgery for weight loss. But here is where the next problem looms: the cost of weight-loss surgery.
Due to the need of advanced equipment and highly experienced professionals to perform the surgery, bariatric procedures such as gastric sleeve surgery, gastric bypass, gastric banding, and others come at a very high price, and only those with sufficient financial resources are able to enjoy this privilege.
Gastric Sleeve now covered.
After the coverage approval of three other bariatric procedures (Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and biliopancreatic diversion with duodenal switch), the Centers for Medicare & Medicade Services or CMS announced the insurance approval of laparoscopic sleeve gastrectomy (LSG) to treat clinically obese individuals.
Gastric sleeve surgery, also known as sleeve gastrectomy involves the removal of 60-80% of an individual’s stomach, leaving a sleeve-like pouch that can lessen his or her appetite. This has been performed on morbidly obese individuals for around a decade already but has become covered by insurance only today.
Who are qualified?
To be an eligible beneficiary of gastric sleeve surgery, three criteria should be met:
- Having a body-mass index (BMI) of over 35
- Having at least one other condition that is related to obesity
- Having been unsuccessful with previous medical treatments for obesity
Does this apply to all insurance contractors?
No. Not all insurance contractors cover this as the CMS has not issued a National Coverage Determination. According to the memo, they left it to the discretion of the local Medicare contractors.
“Our local contractors are in a better position to consider characteristics of individual beneficiaries and the performance of eligible bariatric centers within their jurisdictions,” the memo states.
What’s stopping them?
CMS finds that the results of sleeve gastrectomy in patients over the age of 60 are still in question. “The available evidence does not clearly and broadly distinguish the patients who will experience an improved outcome from those who will derive harm such as postoperative complications or adverse effects from laparoscopic sleeve gastrectomy,” the agency’s spokesperson says.
Nonetheless, the CMS made its final decision allowing insurance coverage of LSG because of “the seriousness of obesity [and] the possibility of benefit in highly selected patients in qualified centers.”