All posts in Vertical Sleeve Gastrectomy

The Centers for Medicare and Medicaid Services (CMS) have confirmed the removal of the Non-Covered status indicator for Sleeve Gastrectomy beginning October 1, 2012.

Recent events have been favorable for the continued wide-spread acceptance of the Vertical Sleeve Gastrectomy. CMS, which governs Medicare policy, initially decided against covering the sleeve outside of research protocols back in October of 2011. Through much lobbying by the American Society for Metabolic and Bariatric Surgery, CMS reconsidered its decision and submitted a reversal in June of this year.

Another step in the right direction occurred at the end of August, when the decision was made to officially remove the “Non-Covered” status for the Sleeve. This is a clear message to the regional carriers to start covering the Sleeve Gastrectomy starting this Fall. It’s about time Medicare beneficiaries are given access to this life-changing procedure!

Some of you guys already know this great news… HMSA now covers the Sleeve with the same criteria as for the Gastric Bypass and Band. Basically, a Vertical Sleeve Gastrectomy can be considered for individuals with a BMI greater than 40, or a BMI greater than 35 with some significant health condition.

This has been a long time coming. I remember three years of meetings with the HMSA directors, advising them of the need to cover this procedure with the standard bariatric criteria. It’s about time for the Sleeve to be considered a viable option for surgical weight loss!

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.