Action Request: medicare Changes

[Guest guest]

MEDICARE CHANGES- ACTION REQUEST

If Medicare disallows the DS for all Medicare patients- private

insurance will follow.

Please let Medicare and your elected officials know how your

procedure has changed your life for the positive and that it should

be covered. I feel the type of surgery to be performed should be

decided by the patient and the doctor.

I am waiting on the biliopancreatic diversion with duodenal switch

which I was hoping to have in March 2006. This has a long term

success rate often better than other forms of bypass surgeries. If

Medicare approves the changes- this will not happen. The surgery I

was hoping to have is a proven long term successful surgery.

Comments to: http://www.cms.hhs.gov/mcd/public_comment.asp?

nca_id=160 & basketitem=

Also send a note to your Senator, Representative and President:

http://mygov.governmentguide.com/mygov/home/

here is what Medicare has to say:

" The evidence is not adequate to conclude that the following

bariatric surgery procedures are reasonable and necessary and they

are therefore non-covered for ALL Medicare beneficiaries:

open vertical banded gastroplasty,

laparoscopic vertical banded gastroplasty,

open sleeve gastrectomy,

laparoscopic sleeve gastrectomy,

open adjustable gastric banding,

open biliopancreatic diversion with or without duodenal switch, and

laparoscopic biliopancreatic diversion with or without duodenal

switch.

The two non-coverage determinations in the National Coverage

Determination Manual (NCDM) remain unchanged: Gastric Balloon (NCDM

Section 100.11) and Intestinal Bypass (NCDM Section 100.8). "

TEXT IS BELOW:

Proposed Decision Memo for Bariatric Surgery for the Treatment of

Morbid Obesity (CAG-00250R)

Decision Summary

The Centers for Medicare and Medicaid Services (CMS) proposes that

National Coverage Determination (NCD) Manual sections 40.5 and 100.1

be modified to be consistent with the following conclusions:

The evidence is adequate to conclude that open and laparoscopic Roux-

en-Y gastric bypass (RYGBP) and laparoscopic adjustable gastric

banding (LAGB) are reasonable and necessary for Medicare

beneficiaries who are under 65 years of age, have a body-mass index

(BMI) > 35, have at least one co-morbidity related to obesity, and

have been previously unsuccessful with medical treatment for

obesity. CMS is seeking comment on this evidence and its

implications for coverage, and for the range of patients under age

65 who would be covered. We are particularly interested in comments

on the potential to expand coverage for this population under

the " Coverage with Evidence Development " (CED) option.

In addition, the evidence is adequate to conclude that approved

bariatric surgery procedures for Medicare beneficiaries are

reasonable and necessary if the facility performing the procedure

meets the following CMS facility standards:

Each institution will have a credentialing program that ensures that

surgeons performing bariatric surgery shall have;

appropriate board certification,

training and experience that meet approved nationally recognized

guidelines, and

training and clinical expertise in managing and treating morbidly

obese patients prior to the decision to undertake surgery and have

experience in managing post-surgery patients for at least one year

after surgery.

Each institution will ensure that individuals who provide services

and/or supervise services in the bariatric surgery program are

qualified to provide or supervise such services.

Each institution will have an integrated program for the care of the

morbidly obese patient that provides:

ancillary services such as specialized nursing care, dietary

instruction, counseling, support groups, exercise training, and

psychological assistance as needed;

a multidisciplinary bariatric surgery team with written descriptions

of the responsibilities of each member of the team. The team must be

composed of individuals with the appropriate qualifications,

training and experience in the relevant areas of bariatric surgery,

rehabilitation, critical care anesthesia, and nutrition counseling

for the morbidly obese and post-bariatric surgery patients.

Each institution will establish and implement written policies to

address and document adverse events that occur during the management

of a bariatric surgery patient.

Each institution will have staff and readily available consultants

in cardiology, pulmonology, rehabilitation and psychiatry who have

prior experience with bariatric surgery patients.

Each institution will have a written informed consent process that

informs each patient of: 1) the evaluation process; 2) the surgical

procedure; 3) alternative treatments; 4) national and center-

specific rates for potential surgical risks, hospital lengths of

stays, 30-day mortality and other relevant outcome measures; 5) risk

factors that could affect the success of the surgery; 6) the

patient's right to refuse the intervention.

Each institution will have sufficient operating room tables,

equipment, instruments and supplies specifically designed or

appropriate for bariatric surgery; a recovery room capable of

providing critical care to obese patients; an intensive care unit

with similar capabilities; equipment with manufacturer's

specifications, such as hospital beds, commodes, chairs,

wheelchairs, etc., that accommodate the morbidly obese; and

radiology and other diagnostic equipment capable of handling

morbidly obese patients.

The evidence is not adequate to conclude that open and laparoscopic

Roux-en-Y gastric bypass (RYGBP) and laparoscopic adjustable gastric

banding (LAGB) are reasonable and necessary for Medicare

beneficiaries who are 65 years of age or older; therefore, CMS will

non-cover these procedures in this population.

The evidence is not adequate to conclude that the following

bariatric surgery procedures are reasonable and necessary and they

are therefore non-covered for all Medicare beneficiaries:

open vertical banded gastroplasty,

laparoscopic vertical banded gastroplasty,

open sleeve gastrectomy,

laparoscopic sleeve gastrectomy,

open adjustable gastric banding,

open biliopancreatic diversion with or without duodenal switch, and

laparoscopic biliopancreatic diversion with or without duodenal

switch.

The two non-coverage determinations in the National Coverage

Determination Manual (NCDM) remain unchanged: Gastric Balloon (NCDM

Section 100.11) and Intestinal Bypass (NCDM Section 100.8).

CMS is requesting comment on this proposed decision. We are

specifically interested in comments on the potential to cover the 65

and older population under CED. Though we have not finalized the CED

Guidance Document, we believe this issue does meet the general

guidelines outlined in that draft guidance document. CED would also

allow the expansion of national coverage to this older population,

with some limitations. Adherence to Departmental regulations

including the Health Insurance Portability and Accountability Act

(HIPAA, Public Law 104-191) and human research protections (45 CFR

Part 46) would, as with all CED, be a requirement.

We are also asking for public comment on the facility criteria to

include the potential to establish more definitive bariatric surgery

volume criteria for facilities and surgeons. In addition, we believe

these standards will best be applied by organizations experienced in

this process. Therefore, as part of this proposed decision, we are

requesting comment on appropriate entities to apply these standards.

We are aware that the American College of Surgeons and the American

Society of Bariatric Surgeons have developed accrediting programs

and we are specifically asking for comments about their level of

competence in performing this facility review.