Spring 2009
CMS: No to virtual colonoscopies; yes to bariatric surgery for morbidly obese diabetics
The Centers for Medicare & Medicaid Services (CMS) has determined that there is insufficient evidence that virtual colonoscopy, or CT colonography, as a screening tool for colorectal cancer improves outcomes in asymptomatic, average-risk Medicare beneficiaries when compared with conventional colonoscopy. As a result, in February 2009, the agency issued a tentative decision not to cover virtual colonoscopies for Medicare beneficiaries.
In its proposed decision memo, CMS noted that the CT technique does not detect small polyps as well as the conventional procedure. Additionally, patients must undergo a conventional colonoscopy if polyps are detected in order to have them removed, making the CT scan less cost-effective.
However, a March 13 letter signed by more than 40 lawmakers asked CMS to reconsider the decision, maintaining that Medicare coverage for virtual colonoscopies could encourage more patients to take the screening test for colon cancer and might “potentially close or eliminate the gap” in screening between whites and minorities. A final decision is pending.
In another decision, CMS clarified its policy regarding coverage of bariatric surgery for Medicare beneficiaries, specifying type 2 diabetes as one of the co-morbidities the agency would consider in determining coverage for the surgery.
The decision memorandum released in February 2009 specifies that bariatric surgery will be covered for the morbidly obese who have type 2 diabetes provided the surgery is furnished at a CMS-approved facility. Morbidly obese is defined as a body-mass index (BMI) of at least 35. Bariatric surgery is seen as a “safe, effective weight-loss option,” according to CMS Acting Administrator Charlene Frizzera, to help prevent the health complications associated with morbid obesity.
CMS did not find sufficient evidence that bariatric surgery improves health outcomes for the non-morbidly obese (individuals with a BMI below 35) who have type 2 diabetes. Therefore, Medicare will not cover the surgery to treat type 2 diabetes in these individuals.
Blue Cross and Blue Shield of Florida strives to cover procedures, treatments, devices and drugs proven to be safe and effective for a particular disease or condition and continually looks at new medical advances and technology to determine for coverage and payment purposes if any is superior to those already in use. To understand the criteria used in determining coverage for payment purposes, check our Medical Policies (Medical Coverage Guidelines).