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March 27, 2018

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BMI Key to Medicare Coverage of Bariatric Procedures in Diabetic Patients

April 28, 2009:

The Centers for Medicare & Medicaid Services (CMS) has just released a national coverage determination (NCD) that states that certain bariatric procedures will be covered when specific criteria are met.

Beginning on or after February 12, 2009, CMS has determined that type 2 diabetes mellitus (T2DM) is a comorbid condition related to obesity and improves the health outcomes when there is a body mass index (BMI) that is greater than 35. 

Bariatric procedures, 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) will be covered services when performed on Medicare patients who meet the requirements listed above. 

However, when performed on patients who do not have T2DM and who have a BMI of less than 35, the services are considered not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act, and therefore they are not covered.

It should be noted that this NCD does not change related NCDs 40.5 (Obesity), 100.8 (Intestinal Bypass Surgery), or 100.11 (Gastric Balloon for Treatment of Obesity). Additionally, providers should be aware that treatments for obesity alone remain noncovered, as does use of the open or laparoscopic sleeve gastrectomy, open adjustable gastric banding, and open and laparoscopic vertical banded gastroplasty procedures, regardless of the patient’s BMI or comorbidity status.

Deborah C. Hall
Clinical/Technical Editor


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