Bariatric surgery, diabetes, and Medicare   (February 18, 2009)

I've written previously about bariatric surgery (stomach surgery for obese people) for people with diabetes (PWD). Now there's a new twist: a recent news report indicates that Medicare has apparently approved reimbursement for morbidly obese Medicare beneficiaries who have type 2 diabetes.

But there are caveats:

First, the patient must have Medicare coverage. That means that folks with other insurance plans cannot be assured that their insurance plan will cover the procedure (although frequently private insurance plans subsequently approve coverage if Medicare has authorized coverage).

Second, the patient must be "morbidly obese." This is a technical term, and refers to people who are VERY fat - with BMI of 35 or greater. (Non-obese people have a BMI between 18.5 and 25.)

And third, the patient must have their surgery done in specific facilities: those that are approved ("certified") by the American College of Surgeons or the American Society for Metabolic and Bariatric Surgery. In other words, you can't assume that your friendly local surgeon will be able to get reimbursed by Medicare if he does it in your local community hospital - unless it's a certified facility.

Does this change my prior opinion that bariatric surgery to "cure" diabetes should be considered experimental? No, not at all.

My previous recommendation has been that any person with diabetes who might be contemplating such surgery should be enrolled in a study that's well-designed, and which has appropriate staff at the study site to assist with perioperative problems, and where you as the patient sign an "Informed Consent Form" (ICF) that you know that you are participating in a study.

There's now evidence that indeed diabetes is ameliorated in the short term by this surgery (or more correctly, by the weight loss that occurs as a result of the surgery). That evidence is apparently now strong enough that Medicare is now willing to pay for the surgery for obese PWD, with the caveats I mention above).

But again, my advice to people asking about having surgery to treat their diabetes: Realize that this is experimental surgery, even if short-term improvement of diabetes is likely, and even though Medicare apparently will be reimbursing the procedure. And as such, it remains my opinion that this surgery should only be undertaken in a clinical trial setting, with a highly qualified team, and appropriate safeguards.