Bariatric Surgery for Treatment of Morbid Obesity
Section 40.5 - Revised to include reference to covered
surgical procedures. Section 100.1 - Effective for services on or after February 21, 2006,
Medicare will cover open and laparoscopic Roux-en Y gastric bypass (RYGBP),
laparoscopic adjustable gastric banding (LAGB) and open and laparoscopic
biliopancreatic diversion with duodenal switch (BPD/DS) if certain criteria are met and
the procedure is performed in an approved facility. In addition, effective for services
performed on or after February 21, 2006, Medicare has decided that open vertical banded
gastroplasty, laparoscopic vertical banded gastroplasty, open sleeve gastrectomy,
laparoscopic sleeve gastrectomy and open adjustable gastric banding are nationally noncovered for Medicare. These revisions to sections 40.5 and 100.1 of Pub. 100-03 are
national coverage determinations (NCDs) made under section 1862(a)(1) of the Social
Security Act. NCDs are binding on all carriers, fiscal intermediaries, quality
improvement organizations, health maintenance organizations, competitive medical
plans, health care prepayment plans, the Medicare Appeals Council, and administrative
law judges (see 42 CFR 405.1064, effective May 1, 2005). An NCD that expands
coverage is also binding on a Medicare advantage organization. In addition, an
administrative law judge may not review an NCD. (See 1869(f)(1)(A)(i) of the Social
Security Act.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: April 28, 2006
DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.