On December 3rd, an FDA Advisory Panel ruled in favor of indicating the LapBand procedure for patients with a BMI of 35 and greater, and for patients with a BMI of 30-35 with a significant medical comorbidity. This is a significant step in allowing patients access to surgical weight loss who were excluded previously due to BMI limitations. Keep in mind this is only an Advisory Panel decision, and the FDA will make a final ruling in the next few months. In general, the FDA will follow the recommendations they receive from such panels.
How does this impact us? Well, assuming the FDA makes its final decision in favor, some insurance companies may adjust their coverage criteria to match the FDA guidelines. This would probably increase the number of LapBand procedures being performed in the US.
I am in favor of the current ruling because there are plenty of patients (who I have had to turn away) who would benefit form surgical weight loss and fall within the BMI 30-40 class.
Join us at one of our support groups near you! If you have any questions, please call our office or contact us.
||Kona, Big Island
|Date: 8/23 then 3rd Tuesday at 6:00pm
Maui Medical Group
2180 Main St.
|Date: 8/24, then 4th Tuesday at 6:00pm
|Hilo, Big Island
|Dates: 8/23, then 4th Tuesday at 6:00pm
Living Waters Assembly of God
89 Maikai St.
|Date: 8/23, then 4th Tuesday at 6:00pm
New Beginning Christian Center
3-4251 Kuhio Hwy
The CMS, Centers for Medicare and Medicaid Services, recently announced a decision to review the current literature on the vertical sleeve gastrectomy. CMS determines coverage criteria for surgical weight loss procedures. This is an optimistic step towards possible sleeve coverage by Medicare. A preliminary decision should be released in March 2012, with a final policy decision in mid 2012. Medicare currently only recognizes the Bypass, Band and Switch for surgical weight loss operations performed at Centers of Excellence, COEs.
If Medicare decides to recognize the Sleeve as another option with similar criteria to the current procedures, this could create a wave of private insurers following suit. I personally look forward to seeing UHA and HMA recognize the sleeve, and especially for HMSA to remove their 60 BMI barrier to this operation.
Posted on July 6, 2010 in Latest News, Sleeves
For all you guys wondering what is going on with the Sleeve Gastrectomy in terms of insurance coverage and new research, here’s the scoop:
Insurance coverage: United Healthcare and Aetna (large mainland insurance companies) now cover the Sleeve Gastrectomy under standard NIH criteria. Medicare and local insurances still are reluctant to follow suit, but my guess is that they will do the same in the next year or two.
Basic Science: We have always thought of the Sleeve Gastrectomy as a restrictive procedure, where weight loss is acheived through limiting the amount of food intake. But this category is probably too simplistic. Ghrelin, a hormone produced in the stomach that signals hunger and fullness, is significantly reduced after this procedure. Also, people with diabetes see immediate improvement after this surgery which is most likely due to rapid transit of food to the ileum, initiating hormones that alter glucose metabolism.
With Medicare reviewing its coverage criteria for the Vertical Sleeve Gastrectomy, the American Society for Metabolic and Bariatric Surgery, ASMBS, has decided to update its Position Statement. The ASMBS is the society that represents bariatric surgeons and is also responsible for setting up the Centers of Excellence (COE) Program. Up to now, ASMBS held the position that the Sleeve looked “promising” with early and intermediate follow up data, and that the procedure should be studied more, before a final recommendation for its use would be made. The new statement to be released considers the sleeve as a viable alternative surgery option to the Band and Bypass, and that the SLEEVE CRITERIA FOR COVERAGE SHOULD BE THE SAME AS FOR THE BAND AND BYPASS. This is a great step in the right direction for increasing options for surgical weight loss patients. All of these procedures have their distinct advantages and disadvantages. This should help us match an operation more closely to a patients’ expectations for improved health and weight loss.