does Medicade pay for Lap band??
Hey everyone... I have a question that I hope someone could help me with.. I know the doctor I want to do my surgery accepts Medicade. I go to his Seminar on Monday then I will make an appointment with him after that... My question is - does anyone know if Medicade pays for the Lap band and/or Realize band surgery??.... Thanks alot!
Hi Nichole,
Medicaid does cover LapBand WLS in NC if you meet the requirements outlined in the document link http://www.dhhs.state.nc.us/DMA/physician/1a15.pdf. I pulled up the Centers for Medicare/Medicaid website that indicates that Medicare facilities require a COE. I cannot find anything that indicates of Medicaid also requires a COE or not; however, Monica appears to be very knowledgeable on Medicaid coverage issues.
I hope that you were able to get answers to your question from the insurance specialist at the program you are investigating when you went to the seminar on Monday.
Barbara
Barbara
ObesityHelp Coach and Support Group Leader
http://www.obesityhelp.com/group/bcumbo_group/
High-264, Current-148, Goal-145
Go to : www.ncdhhs.gov/dma/physician/1a15.pdf << clickable link
Print it out and make sure you have all the qualifications they require. Its not tough.
My surgeons office sent my packet in for approval on a Wednesday and I called them the following Tuesday to hear an approval. WOO HOO. I am getting RNY but the approval process is the same.
If you have any questions, please just PM me and I will help as much as I can.
NC Medicaid will pay for the Gastric Band and the Roux-en Y (RNYGB) if you meet their criteria, whi*****ludes a 6 month medically supervised diet by your PCP (Primary Care Physician) AND that means once a month every month for 6 consecutive months where you discuss diet/exercise/behavior modification and it MUST be documented by your PCP.
Medicaid is very specific, but they will go into detail at the seminar and will be sure to give details about how to make your appointment after you have completed at least 3 months of that 6 month supervised diet plan.
I am very excited for you, you seem to be doing a lot of homework, good luck!! 
But the pre-requirements changed alot too:
Medical record documentation substantiates all of the following information:
1. The recipient has attempted weight loss in the past without successful long-term weight reduction.
2. The recipient has met either criterion (a) or criterion (b) below:
(a) Physician-supervised nutrition and exercise program: The recipient has participated in physician-supervised nutrition and exercise program (including dietician consultation, low-calorie diet, increased physical activity, and behavioral modification), documented in the medical record. This physician-supervised nutrition and exercise program must meet all of the following criteria:
(1) Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and
(2) Nutrition and exercise program(s) must be for a cumulative total of 6 months or longer in duration and occur within 2 years prior to surgery, with participation in one program of at least 3 consecutive months; and
(3) Recipient’s participation in a physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who supervised the recipient’s participation. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician.
Note: A physician’s summary letter is not sufficient documentation. Documentation should include medical records of physician’s contemporaneous assessment of patient’s progress throughout the course of the nutrition and exercise program. For recipients who participate in a physician-administered nutrition and exercise program (such as MediFast or OptiFast), program records documenting the recipient’s participation and progress may substitute for physician medical records;
or
(b) Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery, the recipient must participate in an organized multidisciplinary surgical preparatory regimen of at least 3 months’ duration, meeting all of the following criteria, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the recipient’s ability to comply with postoperative medical care and dietary restrictions:
(1) Consultation with a dietician or nutritionist; and
(2) Reduced-calorie diet program supervised by dietician or nutritionist; and
(3) Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and
(4) Behavior modification program supervised by qualified professional; and
(5) Documentation in the medical record that the recipient has satisfactorily complied with the multidisciplinary surgical preparation regimen.
Note: A physician’s summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician’s initial assessment of the recipient, and the physician’s assessment of the recipient’s progress at the completion of the multidisciplinary surgery preparation.
Note: These medical record entries must indicate individualized intervention (prewritten entries to which only the date, recipient’s name, and vital signs are entered do not document the specific interaction that occurred on that date).
and
e. The recipient has no correctable cause for the obesity, such as an endocrine disorder.
and
f. There is medical record documentation of a psychological evaluation assessing the recipient’s suitability for surgery and his or her ability to comply with lifelong dietary changes and medical follow-up. Components of such an assessment should include
1. levels of depression due to increased risk of suicide
2. eating behaviors
3. substance abuse evaluation
4. stress management
5. cognitive abilities
6. social functioning
7. self-esteem
8. personality factors or other mental health diagnoses that may affect treatment
9. readiness and ability to adhere to required lifestyle modifications
10. follow up/social support
Note: Providers should consider after-care follow up if issues are identified.
They also now pay for revisions:
3.3 Revision of Bariatric Surgery
Medically necessary surgery to correct complications from previous bariatric surgery, such as obstruction and stricture, as described in Section 1.5, is covered. The following are examples of conditions and/or diagnoses for which revisions to the primary procedure for morbid obesity may be covered:
a. weight loss of 20% or more below the ideal body weight
b. esophagitis, unresponsive to nonsurgical treatment
c. hemorrhage or hematoma complicating a procedure
d. excessive bilious vomiting following gastrointestinal surgery
e. complications of the intestinal anastomosis and bypass
f. stomal dilation, documented by endoscopy
g. documented slippage of adjustable gastric band
h. pouch dilation documented by upper gastrointestinal examination or endoscopy, producing weight gain of 20% or more, provided that
1. the primary procedure was successful in inducing weight loss prior to the pouch dilation, and
2. the recipient has been compliant with a prescribed nutrition and exercise program following the procedure (weight and BMI prior to surgery, at lowest stable point, and at current time must be submitted along with surgeon’s statement to document compliance with diet and exercise)
i. other and unspecified post surgical non-absorption (such as hypoglycemia and malnutrition following gastrointestinal surgery)
