How Does NE medicare/ medicade deem 'medical necessary'

for plastics? 

Here is my delima.

I had WLS one year ago.  I have about 40 pounds to go to make goal weight, but probably about 10-15 of it is excess skin in my tummy.  I have fought infections under my tummy for about 16 yrs due to repeated c-sections and the extra skin of being fat.  Now it is worse due to the excess skin from losing weight.  I add to that a diagnosed small hernia in my belly button that needs repaired AND now with the excess skin infections inside my belly button.  All have been documented, the infections under my tummy for several years.  

My question is:  Has anyone gone through medicare/medicaid in NE to get this type of problem taken care of?  I was told that IF I sign a waiver, Methodist would do it, but no guarantee that medicare/medicaid would cover it, and they won't even submit PRIOR to surgery, you just have the surgery, sign a waiver that you will pay XXX amount and that is that.  My problem is there is no way I have XXXX amount to pay it, who does if they are disabled and have this insurance?  That is why we have the insurance.  

Can anyone point me to a doc that would do it, that is approved and the procedure of continuing to get medicare/medicaid to cover it.  It HAS to be done for me to be able to work, the smell of this infection is horrible not to mention the pain and discomfort of it.  I have tried to have it treated, and only have been told that an antifungal is what will work, and it doesn't even clear it up, it tames the pain and itching, but never has completely cleared it up. 

Thanks! 

Hi Laurie;
Maybe I can help. I first saw Dr. Gary Anthone on Sept 3, 2008 to discuss having a DS. When I saw him the first thing he said was that he wanted to do a Panniculectomy on me. This surgery was to remove the fat in the area below my bellybutton and between my legs; I also had an umbillical hernia.He explained that the Panniculectomy would normally be done to take off the excess skin after I had achieved my maximum weight loss. In other words it is a glorified " tummytuck " . I was worried about the cost of two surgeries since I am disabled; living in a nursing home and my only coverage is through Medicare/Medicaid. It is important to call it a Panniculectomy because a Tummytuck is considered cosmetic. I had the surgery on 12/1 and he removed 47 pounds of fat and skin; now I am scheduled to have my DS on August 11 th. This surgery and the previous one were done at Methodist.

I think if you call Dr. Gary Anthone and explain your situation and ask him about a Panniculectomy; he might be able to help. Feel free to email me if you have any other questions.

Good Luck;
Michael

Thanks!  I see him in 6 months, and until I am comfortable with my weight and feel that is where I want to be, then will talk to him.  

I will remember that it can be called something else...

Having the documentation is crucial so you are one step ahead already. If I am remembering right you are close to Kearney. Call Dr. Atchison, his staff is good with approvals and should be able to get you some additional information.

Michelle

I contacted Dr. Atchison, he basically told me won't go.  No let me see you in the office and lets see what we can do or anything. 

I think that I will not have my insurance soon.  DH got a raise, and we are to 1 kid in the house, barley in the guidelines for me to be on now and with his raise I know it will go bye bye.  :(  Guess no tummy tuck or hernia repair for me.  

Thanks for the suggestion.