NCD 100.1: Bariatric Surgery for Morbid Obesity
Medicare covers Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, BPD-DS, and laparoscopic adjustable gastric banding for patients meeting BMI + comorbidity + behavioral criteria.
What's covered
- Roux-en-Y gastric bypass
- Laparoscopic sleeve gastrectomy
- BPD-DS (biliopancreatic diversion with duodenal switch)
- LAGB (laparoscopic adjustable gastric band)
- Revisional surgery in specific failure scenarios
Coverage criteria
- BMI ≥35 with one or more comorbidities (T2DM, HTN, OSA, NAFLD)
- OR BMI ≥40 without comorbidities
- Documented attempts at medical weight loss
- Psychological evaluation
- Multidisciplinary team approach
- Approved facility (since 2013 NCD update removed Center of Excellence requirement)
Exclusions
- BMI <35
- BMI 35-39.9 without comorbidity
- Active substance abuse
- Active uncontrolled mental illness
Common denial patterns
- BMI documentation conflicts
- Comorbidity not adequately documented
- Missing psychological eval
- Inadequate documentation of prior weight-loss attempts
Appeal citation
NCD 100.1 (Bariatric Surgery), 2013 revision. Cite BMI, comorbidity diagnosis codes, psych eval date, weight-loss attempt documentation.
Frequently asked questions
What does Medicare NCD 100.1 cover?
Medicare covers Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, BPD-DS, and laparoscopic adjustable gastric banding for patients meeting BMI + comorbidity + behavioral criteria.
What are the coverage criteria?
BMI ≥35 with one or more comorbidities (T2DM, HTN, OSA, NAFLD); OR BMI ≥40 without comorbidities; Documented attempts at medical weight loss; Psychological evaluation; Multidisciplinary team approach; Approved facility (since 2013 NCD update removed Center of Excellence requirement).
What is excluded?
BMI <35; BMI 35-39.9 without comorbidity; Active substance abuse; Active uncontrolled mental illness.
How do I cite this NCD in an appeal?
NCD 100.1 (Bariatric Surgery), 2013 revision. Cite BMI, comorbidity diagnosis codes, psych eval date, weight-loss attempt documentation.
Sources
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