30 PRACTICE TRENDS JANUARY 15, 2009 • FAMILY PRACTICE NEWS CMS Clarifies Bariatric Surgery Coverage Criteria

BY JOYCE FRIEDEN In 2006, the CMS issued a national CMS was responding to a trend in the of endocrinology, diabetes, and bone dis- Senior Editor coverage decision for bariatric surgery medical literature and meeting presenta- ease at the Mount Sinai School of Medi- in morbid obesity. It said Medicare tions suggesting that bariatric surgery cine, in New York. edicare will not cover bariatric would cover three procedures—open might be helpful for even those diabetes He noted that although the CMS does surgery for beneficiaries who and laparoscopic Roux-en-Y gastric by- patients who are not overweight. “A lot of not currently cover the surgery for pa- Mhave type 2 diabetes but do pass surgery, open and laparoscopic bil- surgeons began noticing that after tients with a BMI under 35 that could not have a body mass index greater iopancreatic diversion with duodenal bariatric surgery, patients with diabetes change if long-term follow-up data on the than 35 kg/m2, according to a pro- switch, and laparoscopic adjustable gas- had amelioration of their hyperglycemia. procedure became available. posed decision memo. tric banding—for beneficiaries with a ... But they found that a lot of the im- Dr. Schauer said he was pleased that the Recent medical reports have claimed BMI greater than 35, at least one co- provement was independent of weight agency reaffirmed its support for surgery that bariatric surgery may be helpful for morbidity related to obesity, and who loss; there was something else,” he said. for diabetes patients with the standard such patients, but the Centers for had been previously unsuccessful with There were two hypotheses: proximal BMI threshold of 35 kg/m2 or above. “Of Medicare and Medicaid Services “did medical treatment for obesity. changes, such as factors in the proximal all insurers private and public, CMS has not find convincing medical evidence At that time, the agency asked for small bowel, and distal changes, such as had the most expansive coverage of that bariatric surgery improved health comments on whether Medicare glucagonlike protein-1 and other factors surgery so far; a lot of private carriers ei- outcomes for non–morbidly obese in- should cover various gastric and in- made by the small bowel in the distal ther don’t cover the surgery at all or put dividuals,” it said in a statement. testinal bypass procedures to improve ileum, said Dr. Mechanick, who is also di- a lot of non–evidence-based hurdles in Dr. Barry Straube, the agency’s di- diabetes status in obese, overweight, rector of metabolic support in the division front of access to care,” he noted. ■ rector of its Office of Clinical Standards and nonoverweight diabetes patients. and Quality, said, “Limiting coverage of The proposed decision memo is an bariatric surgery in type 2 diabetic pa- outcome of that query; the CMS ac- tients whose BMI is less than 35 is part cepted comments on the memo until Medicare Advisers Back CT of Medicare’s ongoing commitment to mid-December. The agency had up to ensure access to the most effective 30 days to issue a final decision memo, treatment alternatives with good evi- which is available online at www.cms. Colonography, With Caveats dence of benefit, while limiting cover- hhs.gov/mcd/index_list.asp?list_type= age where the current evidence sug- nca; click on “Surgery for Diabetes.”) BY ALICIA AULT But many committee members said gests the risks outweigh the benefits.” Dr. Jeffrey Mechanick, who cochaired Associate Editor, Practice Trends they were quite concerned about those The proposal also clarifies that type 2 a bariatric surgery guidelines commit- extracolonic findings, and said that they diabetes is one of the comorbidities that tee for the American Association of B ALTIMORE — After a daylong dis- could skew both the health benefits of would be acceptable criteria for surgery. Clinical Endocrinologists, said that the cussion, a panel of Medicare advisers ten- the procedure and its potential cost-ef- tatively said they support use of comput- fectiveness. ed tomographic colonography to screen Dr. Mary Barton, scientific director of for colorectal cancer in average-risk the U.S. Preventive Services Task Force, CLASSIFIEDS Medicare beneficiaries. told the panel that the task force’s sys- www.familypracticenews.com The Medicare Evidence Development tematic review of CTC found that it and Coverage Advisory Committee was comparable to optical colonoscopy (MEDCAC) was given an overview of in sensitivity and specificity for lesions CONTINUING EDUCATION existing evidence on sensitivity, specifici- larger than 10 mm, but not quite similar ty, and cost-effectiveness of the technolo- for lesions larger than 6 mm. gy, and then was asked to vote on a series Colonoscopy has the potential for se- of questions gauging panelists’ level of rious harm in 28 per 10,000 patients, STOP Going to Sales confidence in computed tomographic partly because of the risk of perforation, “Seminars” URGENT CARE MEDICINE colonography (CTC) as a screening tool, Dr. Barton said. While CTC has no sig- Start learning one-on-one from THE FUTURE OF HEALTHCARE when compared with optical colonoscopy. nificant harms per 18,000 patients, there Aesthetic Medicine Professionals. Urgent Care Medicine is one of the fastest growing segments of the health care field – Join us as we advance The Centers for Medicare and Medic- is uncertainty regarding the radiation Just like your practice, the field of Urgent Care Medicine! aid Services is considering whether to of- exposure, extracolonic findings, and false aesthetic laser patients are diverse. The American Academy of fer coverage of CTC. The agency already positives, she said. All ages, skin types, from all walks of life Urgent Care Medicine (AAUCM) is the leading society for pays for colorectal cancer screening for av- Dr. Ned Calonge, chairman of Pre- Free Introductory Preceptorship physicians, physician assistants No Franchise Fees Involved and nurse practitioners practicing erage-risk individuals aged 50 and older ventive Services Task Force and chief CASH Procedures urgent care medicine. using fecal occult blood testing, sigmoi- medical officer of the Colorado De- • Board Certification in Urgent Care Medicine • Laser Hair & Spider Vein • Laser Skin Resurfacing • Accredited by the ACCME to provide CME doscopy, colonoscopy, and barium enema. partment of Public Health and Envi- Removal • Benign Mole Removal • Urgent Care Center Accreditation • Pigment Removal • Wrinkle Reduction • Annual Conferences In March, the American Cancer Society, ronment, said that the unknowns about • Acne/Scarring Treatments • Tattoo Removal • Member Benefits include a complimentary subscription to the EMERGENCY the U.S. Multi-Society Task Force on Co- these potential harms led the group to • Skin Tightening & MEDICINE/URGENT CARE Journal as Rejuvenation Treatments well as various discount programs such lorectal Cancer, and the American College give CTC a grade of “I,” for insufficient Medical Malpractice Insurance, EMRs, INCORPORATE AESTHETIC and more of Radiology issued new cancer screening evidence. “This is really a call for further MEDICINE INTO YOUR PRACTICE! Join TODAY! guidelines, which included the statement research,” Dr. Calonge told the that CTC was an acceptable option. Medicare advisers. A majority of the MEDCAC panelists Dr. Jason Dominitz of the University Visit www.aaucm.org or call 407-521-5789 to learn more! were moderately to highly confident of Washington, Seattle, who spoke on that there is sufficient evidence to deter- behalf of the American Society for Gas- FOR CLASSIFIED RATES mine sensitivity and specificity of CTC trointestinal Endoscopy, agreed that the Thomas Sult, MD Robin Sult, RN AND INFORMATION: in screening for polyps that measure 6 jury was still out on CTC. “It’s our over- Traci Peppers, Elsevier-Family Practice Visit www.aestheticclinic.net News, 360 Park Avenue South, New mm to less than 10 mm, and for polyps all belief that it’s premature to endorse AESTHETIC LASERS, INC. York, NY 10010. (212) 633-3766. Fax: larger than 10 mm. They were less con- CTC for average-risk Medicare benefi- 877-868-3757 (212) 633-3820. Email ad to: [email protected] fident that the evidence could determine ciaries at this time,” Dr. Dominitz told specificity and sensitivity for polyps the committee. smaller than 6 mm. The screening should be offered to Disclaimer Most panelists said that CTC would people with incomplete colonoscopies or FAMILY PRACTICE NEWS assumes the statements made in classified advertisements are provide a net health benefit for average- to those who refuse to undergo that accurate, but cannot investigate the statements and assumes no responsibility or liabili- ty concerning their content. The Publisher reserves the right to decline, withdraw, or edit risk Medicare beneficiaries—that is, a test, but otherwise, there are too many advertisements. Every effort will be made to avoid mistakes, but responsibility cannot be decrease in morbidity and mortality questions, including questions about its accepted for clerical or printer errors. from identification and removal of sensitivity for small and flat polyps, how polyps, when balanced against the risks to manage extracolonic findings, the ra- of the procedure and the identification diation risk, and the appropriate intervals Also available at www.elsevierhealthcareers.com of extracolonic abnormalities. for CTC screening, he said. ■