CodeMap® LCD-L34576

Contractor Information

Contractor Name: Palmetto GBA - Full list of policies of this Medicare Contractor

Contractor Number: 11502
Contractor Type: MAC B

LCD Information

LCD ID Number: L34576 Status: A-Approved
LCD Title: Laparoscopic Sleeve Gastrectomy for Severe Obesity
Geographic Jurisdiction: North Carolina Other Jurisdictions
Original Determination Effective Date: 10/01/2015
Original Determination Ending Date:
Revision Effective Date: 01/11/2024
Revision End Date:
CMS National Coverage Policy:
Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnoses or treatment of illness or injury or to improve the functioning of a malformed body member.

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §100.1 Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity

Decision Memo (CAG-00250R2) for Bariatric Surgery for the Treatment of Morbid Obesity, June 27, 2012, Medicare Administrative Contractors acting within their respective jurisdictions may determine coverage of stand-alone laparoscopic sleeve gastrectomy (LSG) for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries only when all of the following conditions A-C are satisfied.
A. The beneficiary has a body-mass index (BMI) ≥ 35 kg/m2,
B. The beneficiary has at least 1 co-morbidity related to obesity, and
C. The beneficiary has been previously unsuccessful with medical treatment for obesity.

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12/10/2024 05:38:27 18.97.14.84

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