Medicare to pay for a variety of obesity surgeries

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WASHINGTON - Obese elderly or disabled patients are now eligible for a variety of surgical weight-loss procedures under the U.S. Medicare health insurance plan, U.S. government officials said on Tuesday.

Patients must have tried but failed with other weight loss options, have at least one weight-related medical problem and have a high body mass index, the Centers for Medicare and Medicaid Services said.

Previously, Medicare patients could only receive gastric bypass surgery, in which the lower part of the stomach is either closed off or removed and its contents detoured around the large intestine directly to the small intestine.

But Tuesday's final ruling opens the door to laparoscopic adjustable gastric banding that squeezes the stomach smaller with a small band.

Companies that make stomach bands and other devices for weight-loss procedures, including Inamed Corp., Tyco International Ltd.'s US Surgical, and Johnson & Johnson unit Ethicon Endo-Surgery Inc., had asked Medicare to consider coverage.

Privately-held Transneuronix Corp. as well as the American Society for Bariatric Surgery and the American Obesity Association also made the request.

The decision may help set coverage standards for insurance companies, which eye agency decisions before setting their own policies.

Medicare officials had earlier proposed coverage only for disabled patients, citing possible risks for the elderly. Under the final decision, older patients can only receive the procedure at medical centers that treat large numbers of patients and have low death rates.

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Medicare to cover surgery to treat obesity By Julie Appleby, USA TODAY

Medicare said Tuesday that it will pay for three forms of an expensive surgery to treat obesity, so long as the patients are treated in "high-volume centers that achieve low mortality rates."

The move comes after device makers, surgeons and some patient advocates urged the agency to create a uniform national policy on bariatric surgery, which can cost $15,000 to $20,000 per procedure. Previously, coverage decisions varied by region.

The impact will go beyond Medicare: Private insurers, which vary widely on whether they cover the surgery, often follow Medicare's lead. For example, when Medicare decided to cover organ transplants, insurers began to pay for them.

Previously, Medicare officials said they were considering limiting the surgery to those under age 65, for safety reasons. But after reviewing new data, Medicare officials said experienced surgeons have similar outcomes for patients of all ages and they will pay for the surgery for any age.

At high-volume centers, the mortality rate from the surgery is less than 1%, Medicare says. Overall, the rate is in the 4% to 6% range.

To qualify for the surgery, patients must have unsuccessfully tried other treatments, have a body mass index of more than 35 and also suffer from weight-related problems, such as diabetes, heart disease or sleep apnea, the agency said.

Medicare paid for about 2,000 such surgeries in the over-65 age group in the past seven years and 20,000 cases in those under 65, who qualify for Medicare because they are disabled.

The agency says it does not have dollar-cost estimates on how much the new procedure will add but says it will be far less than what it spends on coronary bypass or heart defibrillators.

Surgery advocates say the ruling could save Medicare money in the long run because patients' health will improve and some could even come off of disability rolls.

"It will cost less to take care of them," says Harvey Sugerman, immediate past president of the American Society for Bariatric Surgery.

The three types covered are:

• The Roux-en-Y bypass, the most common bariatric surgery and the only type previously covered by Medicare, uses surgical staples to create a small pouch in the stomach connected to the bowel by a piece of the small intestine, bypassing the majority of the stomach.

• Open and laparoscopic biliopancreatic diversions involve surgically bypassing most of the small intestine and pancreas.

About 65% of American adults are overweight or obese, which increases their risk of heart disease, type 2 diabetes, cancer and many other diseases. And they are increasingly turning to bariatric surgery.

A study published in the December Archives of Surgery found that such operations increased 450% from 1998 to 2002, going from 12,775 to 70,256 cases. That number had increased to 140,640 by 2004, and the 2005 number was estimated at 171,200, according to the American Society for Bariatric Surgery