medicare coverage variances depending on state

I wanted to share some information I just gathered for myself in case anyone else on Medicare ever encounters the same situation when discussing payment criteria for WLS.  Because Medicare apparently uses coverage administrators, the requirements vary from state to state.  In my instance, I live in Tennessee, but I believe the patient advocate at my clinic was viewing information for Texas, which has slightly stricter and more specific qualifications.  This was a possible wall for me as I am depending on my recent diagnosis of hypertension to have WLS covered, but I have only tried one medication so far.  I've pasted part of the blog entry below.  You may view the blog entry in whole here.

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I went to the cms.gov Medicare Coverage Database and did a search of local documents for bariatric surgery.  I did one for Texas and one for Tennessee.  I confirmed that Texas' MAC (Master Administrative Contracter) is Trailblazer.  Their documented requirements for bariatric surgery do specify the following:

• - A body mass index of 35 or higher.
• - At least one comorbidity related to obesity.
• - Have been previously unsuccessful with medical treatment for obesity.
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Additionally, they define the comorbidities as:

• - Type II diabetes mellitus (by American Diabetes Association diagnostic criteria).
• - Refractory hypertension (defined as blood pressure of 140 mmHg systolic and/or 90 mmHg diastolic despite medical treatment with maximal doses of three antihypertensive medications). [emphasis mine]
• - Refractory hyperlipidemia (acceptable levels of lipids unachievable with diet and maximum doses of lipid lowering medications).
• - Obesity-induced cardiomyopathy.
• - Clinically significant obstructive sleep apnea.
• - Obesity-related hypoventilation.
• - Pseudotumor cerebri (documented idiopathic intracerebral hypertension).
• - Severe arthropathy of spine and/or weight-bearing joints (when obesity prohibits appropriate surgical management of joint dysfunction treatable but for the obesity).
• - Hepatic steatosis without evidence of active inflammation.
•  

A local search for Medicare coverage in my state showed that the MAC in Tennessee is Cahaba Government Benefit Administrators^®.  Their coverage documentation was a little more technical in terms, but I was able to read it.  (Thank you previous jobs in medical billing!)  It also states that bariatric surgery is payable under the specifications outlined in the National Coverage Database, which states:


"Effective for services performed on and after February 21, 2006, Open and laparoscopic Roux-en-Y gastric bypass (RYGBP), open and laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS), and laparoscopic adjustable gastric banding (LAGB) are covered for Medicare beneficiaries who have a body-mass index > 35, have at least one co-morbidity related to obesity [emphasis mine], and have been previously unsuccessful with medical treatment for obesity."


The appropriate comorbidities were listed in too great of detail on the local coverage documentation for Tennessee to be included here in this post, but ICD-9 codes 401.0-401.9 were listed, which is simple hypertension, and no previous treatment attempts were required.

- Have been previously unsuccessful with medical treatment for obesity.
Do you know what Medicare's specifcs are on this criteria?