Medicare coverage for VSG is currently under review

Medicare coverage for VSG is currently under review, folks!  We may finally see VSG covered by Medicare by the end of June, 2012!  That should cause other insurers to move as well.

 

CMS, the Centers for Medicare and Medicaid Services, which really “is" Medicare, announced on 09/30/2011 that it’s soliciting comments on a proposal to cover laparoscopic sleeve gastrectomy (VSG) for Medicare patients.  The Public Comment Period is from 9/30/2011 - 10/30/2011. The Proposed Decision Due Date is 03/30/2012 with a final decision by 6/28/2012.  The big question appears to be availability & sufficiency of long-term data.

 

You can see the CMS Solicitation for Comments and read submitted comments at https://www.cms.gov/medicare-coverage-database/details/nca-t racking-sheet.aspx?NCAId=258&fromdb=true .

 

Also, in addition to the CMS info, the Internal Medicine News Digital Network reported that “A recent observational study presented at the annual meeting of the American Surgical Association found that at 1 year after surgery, LSG was associated with morbidity and effectiveness rates that fell between those of laparoscopic adjustable gastric banding and laparoscopic Roux-en-Y bypass procedures.

The absolute reduction in BMI at 1 year was smallest in the laparoscopic adjustable gastric banding group at about 6, greatest with open or laparoscopic Roux-en-Y gastric bypass at about 15, and intermediate at close to 12 with LSG.

The study, based on prospective, longitudinal, standardized data from 109 hospitals, was the first to come out of the ACS Bariatric Surgery Center Network accreditation program. Additional years of follow-up are planned, according to Dr. Matthew M. Hutter, an ACS Fellow with Massachusetts General Hospital, Boston."  (Source: http://www.internalmedicinenews.com/news/gastroenterology/si ngle-article/cms-considers-coverage-of-laparoscopic-sleeve-g astrectomy/fc3fe54035.html )

Harv

I spoke with my Bariatric Surgeons P.A. today and discussed the Medicare coverage review of the VSG. He told me based on his attendance at the annual Bariatric Surgeons convention he was told coverage for the VSG is very likley to be approved for Medicare. He did not want to cite names but did say this tip off came from very reliable sources close to the review process. He went so far as to say (without prompting) "He would be shocked if the review panel rejected covering it this year".

Im starting my 6 month required supervised diet (ie Nutritionist) consultations now to be ready for submittal come October when Medicare updates it's coverage. Those of you on Medicare and Medicade who have been holding out for VSG surgery coverage I strongly suggest contacting your Hospitial's Bariatric cordinator and starting the nessicary legwork now. Starting now, I will have everything needed for insurance approval ready to go the moment coverage goes live.

In closing, just a reminder that the review board for Medicare will be posting a memo indicating their purposed decision and findings in just a couple of weeks (3/30/2012). Final binding decision by no later than 6/28/2012.

~Greg

Thanks for the report, Greg.  Since we also have felt quite confident that CMS will decide to approve VSG, that's what my wife and I are doing, too (i.e., getting all the preconditions satisfied so we are "ready to go into surgery"). 

It is noteworthy that CMS initiated the "solicitation for comments" on their own, which we believe indicated that CMS already knew with some strong likelihood the final decision before they even started the review ... because all the data that has been generated is very consistent ... that VSG is far superior to lap band and will save money for Medicare.  So I believe that your advice to start the approval process is "right on"! 

I had planned to go self-pay since I was concerned that I couldn't risk waiting for Medicare to reach a decision to approve VSG ... but when I learned on October 7 that CMS had a week earlier announced the Solicitation for Comments and announced the timeline for a decision, I decided to wait because the evidence indicated a strong likelihood of a decision to approve VSG.  Because VSG is the only type of gastric surgery we would consider (as I suspect is also true for many other people), the likely imminent decision from CMS is MAJOR to us! 

Because my wife's medical situation is tenuous and any surgery is risky, we only feel comfortable with her VSG being done at Mayo Clinic in Rochester (in case of problems during surgery), and VSG is the type that Mayo recommended for her, given her situation.  But the cost of self-pay at Mayo was likely going to be about $40,000.  So the CMS decision is potentially a matter of life or death for her.

Again, thanks for the info, Greg!  Here's hoping!  8>)

The memo has been issued!

www.cms.gov/medicare-coverage-database/details/nca-proposed- decision-memo.aspx

Unfortunatley, and to my great dissapointment CMS has purposed NOT covering the VSG at this time. However, they say they will cover it (ie pay) under a clinical study provided all the required guidelines are met.

Just fired off a email to my hostipitals Bariatric director to see if they meet all the requirements and are willing to participate in the clinical study for qualified patients. Im hoping they will answer under the pretence that the Memo carries over as is to the final decision and not blow me off with something like "ask us again when the final decison is given"

Wow, Greg, that news is a real blow to the solar plexus!  I am so disappointed!  Based on their plan, it will likely be 4-5 years before this will be reconsidered, given that the clinical studies will need to include three-year outcomes.  The lag time from now until the clinical studies are even designed and started ... and the time after the studies arefinished to compile the results ... may probably mean even longer than 5 years before the issue is revisited.  Until then, our only option other than self-pay is getting into a clinical study.  I am also going to try to get into a clinical study.  I am so shocked ... and saddened ... that this turned out to be the only feasible route!  So many people are being harmed by this decision, but I do understand why CMS made the decision in light of the lack of adequate available data.

Final Binding CMS Decision (6/27/2012)

www.cms.gov/medicare-coverage-database/details/nca-decision- memo.aspx

VSG MEDICARE APPROVED!! (case per case basis determined by regional Medicare Administrative Contractors)

I Spoke directly with my Bariatric Director this afternoon about Medicare's VSG decision. She reviewed the CMS memo decision and agreed with my interpretation that this decision was a good one and coverage appears imminent. While the "fine" details for Medicare contractors (ie hospitals) have not yet been released (billing code, guidelines for submitting, etc) she did say everything looks like a go and I will be the first patient she submits for Medicare approval next month!

For those of you who have not yet had the opportunity to get a personalized nod of approval from your hospital, read this and you should feel better. This is a summarized analysis and decoding of CMS's VSG memo from The American Society for Metabolic and Bariatric Surgery (ASMBS). A true authority in all matters concerning Bariatric's.

asmbs.org/2012/06/access-to-care-alert-the-cms-final-decisio n/

At long last the wait is FINALLY over!

~Greg