Wednesday, February 15, 2023

Catching Up with OIG: Their take on NCD-LCD Confusion & Bariatric Surgery

The CMS NCD for bariatric surgery dates back more than a decade without revision.  It's worth noting for two reasons.   One, there is a contorted policy twist apparently to make bariatric surgery covered.  It's not enough to have severe obesity (like a BMI of 40 or 50).  You have to ALSO have "a disease" that is being "treated" by bariatric surgery - such as knee pain or diabetes.  This always seemed strange to me.  It's like a smoking cessation benefit that predated a later benefit, the first one required tobacco addiction "and a disease" like emphysema.    Regarding the bariatric surgery NCD, a second factor was its vagueness on some key points.

In February 2022, OIG issued a report on Medicare and implementation of bariatric surgery policy.  

The OIG noted that some sections of the NCD were highly vague, and therefore, required supplementation by LCDs.   However, the OIG then noted the LCDs varied quite a lot, and even taken them at face value, the rules weren't always followed by hospitals and payment systems.  OIG recommended modernizing the NCD to include rules that LCDs were adding post-hoc, and if possible, reduce discrepancies among LCDs.

In an unusual move, CMS took NONE of the OIG suggestions; it rejected all of them.  The rejections didn't always make sense;  CMS retorted that statute did not require LCDs to be uniform.  No, replied OIG, but we never said it did.

You can read the full report, including the quarrel back and forth with CMS, here:

I poked fun at CMS's oddly convoluted reasoning that even grave obesity (BMI 50) is 'not a disease' and can only be medically treatable if the bariatric surgery "treats another disease" like knee failure.  See two current news articles on obesity viewpoints,