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CMS Proposes End to Coverage of Obesity Surgery for Medicare Patients 65 and Older

NOVEMBER 23, 2005 -- The Centers for Medicare and Medicaid Services announced a proposal Wednesday to end Medicare coverage of "bariatric surgery" for beneficiaries 65 and older following a recent study showing an elevated risk to the procedure for older patients. However, the proposed "national coverage determination" could lead to more rather than less coverage of the procedure for Medicare's under-65 population.

Stomach-stapling and other forms of "bariatric" surgery have consistently helped patients achieve sustained weight loss and have become increasingly popular as the problem of obesity increases, according to a study published in October in the Journal of the American Medical Association.

Researchers concluded that mortality rates after a year were almost three times higher for beneficiaries 65 or older than for beneficiaries below that age (Medicare covers certain disabled Americans below the age of 64). And the odds of death were 1.6 times higher for patients whose procedure was done by surgeons who had performed a below-average number of bariatric procedures, researchers found.

CMS said that while its proposed national decision would end regional coverage of the 65-and-older group, it is seeking public comment on whether to cover bariatric surgery for older beneficiaries in clinical trials.

The proposed CMS decision would cover certain bariatric procedures for very obese beneficiaries under 65 whether or not they had complicating conditions such as diabetes, a CMS spokesman said. The specific procedures that would be covered for this group of patients are known as "open and laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding" procedures.

But the surgery would have to be performed "in a facility meeting evidence-based standards" for bariatric procedures—an apparent reference to the study data showing better results in higher-volume facilities.

Medicare covered 8,000 bariatric procedures in 2004, 75 percent of them in the under 65 population. On average hospitals received $12,000 for the procedure and doctors $1,000. A total of 6.5 million Medicare beneficiaries are under age 65.

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