In a proposed decision memo, the Centers for Medicare & Medicaid Services (CMS) states that there is little evidence to support open and laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, or open and laparoscopic biliopancreatic diversion with duodenal switch as reasonable and necessary in patients with type 2 diabetes mellitus (T2DM) and a body-mass index (BMI) less than 35.

There is, however, evidence that these types of bariatric surgeries improve health outcomes in Medicare beneficiaries with T2DM and a BMI greater than 35.

CMS is proposing that T2DM is a comorbid condition related to obesity as defined in NCD Manual 100.1 (Bariatric Surgery for Treatment of Morbid Obesity).

CMS is seeking public comment.

4 Responses to “CMS Proposes to Limit Bariatric Surgery Coverage”

1. Peter F Crookes MD Says:
   November 20th, 2008 at 12:25 pm

   I am a bariatric surgeon at a major academic medical center. I write to support the extension of Medicare coverage to diabetic patients with BMI 30-35. CMS has already considered the RCT by O’Brien and Dixon in this population (Ann Int Med 2006;144:625-633), in which the benefits of weight reduction were maintained in the surgery group but disappeared in the medical group. Their further study (JAMA 2008, Jan 23;299(3):316-23) showed 70% remission of diabetes after the Lap Band procedure.

   It has been well established that the best results in acheeving long term remission of Thye 2 diabetes by bariatric surgery are in those with lesser duration of diabetes. Consequently it makes clinical and economic sense to cure the disease earlier in its course.

   One further important point is the fact that many medical antidiabetic treatments cause weight gain. This is especially true of insulin: only metformin amongst common medications does not induce weight gain (De Leeuw I, Vague P, Selam JL, et al. Insulin detemir used in basal-bolus therapy in people with type 1 diabetes is associated with a lower risk of nocturnal hypoglycaemia and less weight gain over 12 months in comparison to NPH insulin. Diabetes Obes Metab.2005; 7:73 -82. UK Prospective Diabetes Study Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet.1998; 352:854 -865.)
   Our own study, recently presented at the Obesity Society meeting, reported that HbA1c improved, but was associated with weight gain in a tightly controlled population of diabetic patients at a large public clinic.

   Denying obese (BMI 30-34.9) patients access to surgery is short sighted because it will merely delay the surgery: motivated patients seeking bariatric surgery will simply gain weight until they fulfil currently acceptable criteria: by which time, they are heavier and the surgery is more difficult and likely to be more problematic. I know from personal clinical experience that this has occurred.

   I strongly urge CMS to re-consider the decision to deny potentially life-enhancing surgery to a group of patients who have even greater potenital to benefit than those with existing organ damage.

   Peter F Crookes MD

2. Peter F Crookes MD Says:
   November 20th, 2008 at 12:31 pm

   I am a bariatric surgeon at a major academic medical center. I write to support the extension of Medicare coverage to diabetic patients with BMI 30-35. CMS has already considered the RCT by O’Brien and Dixon in this population (Ann Int Med 2006;144:625-633), in which the benefits of weight reduction were maintained in the surgery group but disappeared in the medical group. Their further study (JAMA 2008, Jan 23;299(3):316-23) showed 70% remission of diabetes after the Lap Band procedure.

   It has been well established that the best results in achieving long term remission of Type 2 diabetes by bariatric surgery are in those with lesser duration of diabetes. Consequently it makes clinical and economic sense to cure the disease earlier in its course.

   One further important point is the fact that many medical antidiabetic treatments cause weight gain. This is especially true of insulin: only metformin amongst common medications does not induce weight gain (De Leeuw I, Vague P, Selam JL, et al. Insulin detemir used in basal-bolus therapy in people with type 1 diabetes is associated with a lower risk of nocturnal hypoglycaemia and less weight gain over 12 months in comparison to NPH insulin. Diabetes Obes Metab.2005; 7:73 -82. UK Prospective Diabetes Study Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet.1998; 352:854 -865.)
   Our own study, recently presented at the Obesity Society meeting, reported that HbA1c improved, but was associated with weight gain in a tightly controlled population of diabetic patients at a large public clinic.

   Denying obese (BMI 30-34.9) patients access to surgery is short sighted because it will merely delay the surgery: motivated patients seeking bariatric surgery will simply gain weight until they fulfil currently acceptable criteria: by which time, they are heavier and the surgery is more difficult and likely to be more problematic. I know from personal clinical experience that this has occurred.

   I strongly urge CMS to re-consider the decision to deny potentially life-enhancing surgery to a group of patients who have even greater potenital to benefit than those with existing organ damage.

   Peter F Crookes MD

3. Kathryn Cruz, CPC Says:
   November 26th, 2008 at 3:47 pm

   As a hematology coder, I am against the bariatric surgery being used to help those with diabetes mellitus for the reason being more and more patients whom have had this procedure are ending up have a life long battle with iron deficiency having been caused by malabsorption of necessary minerals. Having a nephew who has diabetes mellitus along with congestive heart failure, I have recommended the lap band as a viable alternative for weight loss. Much to my happiness, he has promted himself into a dietary program with his nutritionist and is slowly moving forward toward his weight loss goal. Thank you for this forum.

4. Gwen Raynor, CCS-P Says:
   December 4th, 2008 at 8:06 am

   CMS needs to speak with Dr. Walter Pories who is a pioneer in this surgery. He has published many articles in Medical journals with the results of his research in patients with Diabetes and their amazing results after bariatric surgery.

   He is a professor at East Carolina University in Greenville, NC

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