Medicare requirements
Can anyone tell me what the requirements are for Wellcare (Medicare approved health plan) to get an approval? Wellcare keeps saying that what ever Medicare covers, they cover. My surgeons office called Wellcare last week and they can't tell her what they cover. I'm really afraid that this is going to be a long drawn out process, just for Wellcare to figure out what the heck is going on. I would appreciate any info!
Medicare covers bariatric surgery as long as you meet the NIH criteria. BMI of 40, or BMI 35 with significant co-morbidities.
Medicare does not give a guarantee of coverage prior to surgery, but will determine the level of coverage once the bill is submitted. There are set reimbursements for the surgeon and hospital. All surgeons offices should have a list of the procedures and the reimbursement schedule. (I have one in my office).
Your replacement policy should give your surgeons office verification of credible coverage and the office should then proceed with your work up.
Don't let them string you along and drag it out. It doesn't have to be that way!
Cindy O.
I do not give medical advice. I offer my opinion, nothing more.
on 7/30/09 3:25 am - KY
Good luck with your journey.
50 pounds lost pre-op!
My medicare also required that my surgery be done in a center of excellence that they approved of. You may need to check on that as well. I didn't need the 6 month diet but I think I had to have 2 years of weight history from my PCP as well as his seal of approval. Keep going at it until you get your approval. You may want to check on the social security website. I believe I was able to see what was required that way.
Remember, amateurs made the ark, experts made the Titanic!
CMS has determined that covered bariatric surgery procedures are reasonable and necessary only when performed at facilities that are: (1) certified by the American College of Surgeons (ACS) as a Level 1 Bariatric Surgery Center (program standards and requirements in effect on February 15, 2006); or (2) certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (BSCOE) (program standards and requirements in effect on February 15, 2006).
Medical therapy prior to surgery
One bariatric surgery group wrote that it favored bariatric surgery for those over age 65 and standardized facility criteria, but believed that a medical treatment weight loss trial for 6 to 12 months was not necessary. They commented that the decision of when to perform surgery was best left to the surgeon and the patient.
Generally, a common comment introduced pertained to the subjective nature of the medical treatment requirement prior to surgery. Some stated that there were no data to support such a requirement and others stated that the requirement only prolonged the time to needed surgery.
The standard of care for any surgical procedure is that medical management options are exhaustively considered and exercised by both patient and physician prior to surgery. This standard applies to the treatment of co-morbid conditions related to obesity. We will not impose a specific time period, but expect all surgeons to be part of a comprehensive program for the treatment of co-morbid conditions related to obesity and to have applied principles of good medical care prior to surgery.
https://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?from2=viewd ecisionmemo.asp&id=160&
