Recent Medicare Disability changes for bariatric surgery

HI. I understand Medicare changed their rulings (again!) as of last week. Can anyone give me the "in a nutshell" interpretation and tell me how it might affect me? I am in the "gotta fail the 6 month trial weight loss" period currently, after having found out that Medicare changed their requirements as of October 1, 2005. Thanks!

I think the change that was made last week was that WLS is now only covered at certain approved facilities for Medicare patients over age 65. Basically they want to cut down on the number of complications by having the over 65 candidates go to certain practices that have more experience, lower mortality rates and better care. I could be wrong but I think that was the only change.

Thanks, Leann. I am on Medicare disability and have no other insurance but I do have a couple of co-morbidities that should help. Thanks for the info! Jennie

They are approving RNY and DS for all ages, but only at approved facilites. This will explain it all... http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=160

Oh, and I forgot to mention that as of now, Indiana does not have any approved facilities.

Thanks for the info. My husband had the surgery last April in Merrillville, sounds like the same office you are going to? He is doing great! I will check out the document you are referring to and see what I can find out. I know the Merrillville Methodist Hospital is seeking approval but said it would be between 2 and 6 months before they get it.

Hi Jennie...don't be discouraged by the new changes. This new policy just passed within the last week or so and other facilities are going to get their approval within the next month or so. The new guidelines cover 3 procedures, RNY, adjustable lap-banding and DS. So you will have a choice once you are approved. Keep you chin up and keep pursuing your choice to improve your life.

Thanks Deborah! I appreciate the encouragement!

this is what my man gary sent.....GARY ROCKS and he is all for this surgery and if any way possible he can he will get you approved, he wants to go after walmart and their just say no to WLS Medicare Backs Obesity Surgery U.S. to Pay for Three Types of Stomach-Shrinking Operations By Rob Stein Washington Post Staff Writer Wednesday, February 22, 2006; A08 Medicare endorsed three types of stomach-shrinking surgery yesterday, saying the controversial procedures can offer Americans safe and effective ways to treat obesity. The announcement was seen as a boost for the popular operations, known as bariatric surgery, which had come under a cloud in recent years because of concerns about their safety. "In the right hands, bariatric surgery can benefit patients," said Steve Phurrough of the Centers for Medicare and Medicaid Services, which sets policy for the federal health program. Under the new rules, Medicare will pay for the surgery for obese patients who are suffering from other health problems related to their weight, as long as they undergo the procedure at centers that have been certified as well qualified by the American College of Surgeons or the American Society of Bariatric Surgery. Although some insurers do not cover it, the number of people undergoing the procedures, which cost $25,000 to $40,000, has increased rapidly, jumping from about 16,000 operations in 1992 to an estimated 170,000 in 2005. The decision was hailed by proponents of the surgery, who see it as providing one of the only effective options for Americans struggling with obesity. "This is very positive for millions of Americans," said Morgan Downey of the American Obesity Association. The decision could also open the door for Medicare to cover other treatments for obesity, such as nutritional counseling, physician-supervised weight-loss programs and perhaps weight-loss drugs, Downey said. "We've been waiting to see how they responded to the surgical side. This will give us a cue as to where to go next," Downey said. "I think we'll start seeing Medicare start looking at other interventions." Because private health insurers often follow Medicare's lead, several experts predicted the decision would have broader implications. "The health system in general has largely ignored paying for weight-loss interventions up to this point. This is going to help them reconsider that," Downey said. But critics denounced the decision, saying the procedures are dangerous. "The decision to continue coverage is ill-advised and will expose many people, especially the elderly, to high risk," said Paul Ernsberger of the Case Western Reserve School of Medicine. "There may be some benefits, but there are alternative safe and effective treatments for every obesity-related condition." With one-third of Americans obese, public health experts have become increasingly concerned about the long-term impact on the nation's health. Despite numerous efforts to get Americans to eat better and exercise more, many people find it impossible to lose significant amounts of weight and keep it off, especially those who are extremely overweight. Surgeons perform several variations, but all involve sharply restricting the size of the stomach. The procedures can enable people to lose hundreds of pounds, alleviating disabilities and preventing, even sometimes reversing, serious health problems such as diabetes and high blood pressure. But the rapid increase in the surgeries has raised alarm about their safety, especially when performed by inexperienced surgeons at centers that offer limited follow-up care. Patients are prone to life-threatening complications, including bleeding, blood clots, leakages and infections. Even those with no serious complications can experience unpleasant side effects, including nausea, vomiting and diarrhea. As a result, they require intensive counseling and monitoring. The concerns have led a number of large insurers to refuse to cover the procedures. In October, two large new studies concluded that the surgery is much riskier than had been thought, with patients facing a far greater chance of being hospitalized and dying after the procedures. The following month, the Centers for Medicare and Medicaid Services recommended the program only pay for the operations for the disabled, saying they were too risky for the elderly. But after further analysis indicated that the procedures could be safe for the elderly as long as they are performed by experienced surgeons, the agency decided to approve coverage for them as well, Phurrough said. The coverage will be limited to three of the most commonly performed procedures: Roux-en-Y gastric bypass, gastric banding and biliopancreatic diversion with a duodenal switch, Phurrough said. Best of luck and health. Gary Viscio www.obesitylawyers.com

Thanks Sweet Tweety! I will check out Gary's website also!