A patient undergoing bariatric surgical procedures should undergo preoperative evaluation that is medically reasonable and necessary based upon his comorbid medical conditions and medical/surgical history. All underlying medical conditions that will likely impact or complicate the patient’s surgical and postoperative course must be adequately controlled before surgery. Routine preoperative testing (including upper gastrointestinal endoscopy) in the absence of signs/symptoms or personal history of a disease that could be negatively impacted by anesthesia or surgery is excluded from Medicare coverage by law.
Appropriate postoperative care for the bariatric surgery patient is required for Medicare coverage of bariatric surgical procedures. Follow-up must include but not be limited to:
• Postoperative care by the operating surgeon immediately following surgery and throughout the global period for the surgery.
• At least three follow-up visits with the bariatric surgery team within the first year.
• Lifetime postoperative care for dietary issues (including vitamin, mineral and nutritional supplementation), exercise and lifestyle changes reinforced by counseling and/or support groups supervised by a physician knowledgeable in the long-term care of such patients.
Contraindications to Bariatric Surgery
Surgery for severe obesity is a major surgical intervention with a risk of significant early and late morbidity and perioperative mortality. Surgery for severe obesity is not covered in the presence of absolute contraindications, including the following:
• Prohibitive perioperative risk of cardiac complications due to cardiac ischemia or myocardial dysfunction.
• Severe chronic obstructive airway disease or respiratory dysfunction.
• Non-compliance with medical treatment of obesity or treatment of other chronic medical condition.
• Failure to cease tobacco use.
• Psychological/psychiatric conditions:
o Schizophrenia, borderline personality disorder, suicidal ideation, severe or recurrent depression, or bipolar affective disorders with difficult-to-control manifestations (e.g., history of recurrent lapses in control or recurrent failure to comply with management regimen).
o Mental retardation that prevents personally provided informed consent or the ability to understand and comply with a reasonable pre- and postoperative regimen.
o Any other psychological/psychiatric disorder that, in the opinion of a psychologist/psychiatrist, imparts a significant risk of psychological/psychiatric decompensation or interference with the long-term postoperative management.
Note: A history of or presence of mild, uncomplicated and adequately treated depression due to obesity is not normally considered a contraindication to obesity surgery.
• History of significant eating disorders, including anorexia nervosa, bulimia and pica (sand, clay or other abnormal substance).
• Severe hiatal hernia/gastroesophageal reflux (for purely restrictive procedures such as LAGB).
• Autoimmune and rheumatological disorders (including inflammatory bowel diseases and vasculitides) that will be exacerbated by the presence of intra-abdominal foreign bodies (for LAGB procedure).
• Hepatic disease with prior documented inflammation, portal hypertension or ascites.
Incidental cholecystectomy is covered in the presence of signs and/or symptoms of gallbladder disease, finding of a grossly diseased gallbladder at the time of operation or a history of metabolic derangements that will result in symptomatic gallbladder disease following bariatric procedures.
Repeat Bariatric Procedures
Repeat bariatric surgery is generally not reasonable and necessary. Medicare does not provide prior authorization for these services. Claims for more than one bariatric surgical procedure most likely will create a denial. However, in the appeals process, medical documentation may be submitted for review and the service may potentially be covered when clinical circumstances demonstrate reasonability and necessity. Appropriate ABN and modifiers should be appended to any services potentially to be denied.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Chapter 13, Section 13.5.1, in order to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
• Safe and effective.
• Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, that meet the requirements of the Clinical Trials NCD are considered reasonable and necessary).
• Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
o Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member.
o Furnished in a setting appropriate to the patient's medical needs and condition.
o Ordered and furnished by qualified personnel.
o One that meets, but does not exceed, the patient's medical needs.
o At least as beneficial as an existing and available medically appropriate alternative.