After submitting a formal request for HMSA to review their Vertical Sleeve Gastrectomy Criteria, once again I receive a denial. Bascially, there is growing evidence that the Sleeve procedure provides good weight loss with acceptable safety. How much evidence does an insurance company need before it adjusts their criteria? Well, we have 6 year prospective data in the US, 10 year data internationally, major insurance carriers United Healthcare and Aetna now cover the sleeve, some Blue Cross insurance companies in the US cover the sleeve, our own program has over one year data on HMSA members who have undergone the sleeve and are doing well… and yet they still will not budge!
The good news is that momentum is in our favor to accept the Sleeve as a viable option for surgical weight loss with criteria similar to the Band and Bypass. But, we are going to have to be patient and wait for HMSA to catch up. I still have a hard time rationalizing why we must argue to get our surgeries covered when we know they save lives, improve quality of life, and decrease overall medical costs.
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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.
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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.
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Join us at one of our support groups near you! If you have any questions, please call our office or contact us.
| Maui |
Kona, Big Island |
| Date: 8/23 then 3rd Tuesday at 6:00pm
Location:
Maui Medical Group
2180 Main St.
Wailuku, 96793
Annex Building
|
Date: 8/24, then 4th Tuesday at 6:00pm
Location:
Aloha Center
73-4080
Huilikoa Drive
Kailua-Kona
|
| Hilo, Big Island |
Kauai |
| Dates: 8/23, then 4th Tuesday at 6:00pm
Location:
Living Waters Assembly of God
89 Maikai St.
Hilo, HI
|
Date: 8/23, then 4th Tuesday at 6:00pm
Location:
New Beginning Christian Center
3-4251 Kuhio Hwy
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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.
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