Medicare

Hi!  I have a question... I have Medicare part A and B as well as Texas state Medicaid.  I have already been to a seminar and have 10 months of Dr. supervised weight loss.  I had my stress test, sleep study, psych eval, nutrition... etc.  ALL my tests are complete.  Now I am prepared for the actual surgery, but I have questions on my insurance.  Will Medicare pay?  I know they recently changed the requirements and I don't have diabetes, hypertension or any of the other co-morbidities required.  I have Non-Alcoholic Fatty Liver Disease and I think this is the same as Heapatic Liver Disease which last I heard, was a valid co-morbidity for Medicare.  My BMI is at 58 right now.  Does anyone know of a website that I can go on to check this?  Has anyone been able to get their surgery using Medicare?  Please let me know, as I feel very closeted right now and uninformed.  THANKS!!!  bug

Alrighty.  With your BMI you likely have a lot more co mobidities than you realize.  Are you sure you do not have Type 2 or anything?  Sleep Apnea is a major one that gets people approved and approved on that alone even. Your hospital/dr office of choice will largely handle all of the "getting approved" part.  You should let them thats what they are partly getting $40,000 for and they are experts at it.  So, find a doctor you love and work with them to get your approval.  As far as coverage, if you have that coverage here in Arizona, you are covered.  I do feel it is likely covered in Texas as well.  Good Luck. Lyns

Thanks for your help.  I know that with a BMI this high, I should have some other co-morbidities, but I don't.  Sleep study shows no apnea, and blood work shows no Diabetes.  I've been checked and re-checked and according to the stress test, I have a very healthy heart.  Blood pressure has always been good, around 110 over 70 and outside of fatty liver disease and high/low cholesterol... I can't find medical reasons to justify Medicare paying.  Other than the fact that I'm on disibility and unable to work... back pain, knee pain... general joint pain.  I've had MRI's, CT's, Xrays and all the works.  I'm going to keep up what I'm doing and hope that Heapatic Liver Disease is in fact the same as Fatty Liver Disease.  I've looked it up and it reads complicated.  Anyhow, I appreciate your help... so much.  Sometimes it feels like I'm running around in circles and it would be better to eat junk sugar foods to force myself into Diabetes because at least then it will be reason enough.  I'm just not that stupid, or desperate.  I'm still losing, albiet slowly.  Thanks again, Bug

The last I checked, osteoarthritis/debilitating joint pain counts for a comorbid condition for medicare. If you have joint pain and are overweight, you most likely you have osteoarthritis, all you would need is one joint to xray and have it say OA and you are in. Also incresed triglycerides count, too, especially if you have a family history of heart attack in a parent or sibling. Go to your surgeon's appointment and do not worry!  The surgeon will find a way to get you a good enough diagnosis for medicare. If he says go, it's a go, it is on his shoulders to prove you do not qualify. Every patient has to sign the ABN waiver for services at my office, so do not let that scare you, you will not get a bill for surgery. WLS surgeons love medicare patients, they are the easiest! BTW--Medicare does not approve like regular insurers, it is up to the individual surgeon to make sure you have met the criteria. They do not have to submit to Medicare in advance of the surgery like with other insurers, they submit after.  Also, unlike what the previous poster says---NO INSURER pays a surgeon $40,000. TRY MORE LIKE $2500, YES--I SAID TWENTY FIVE HUNDRED!  Insurers reimburse less than $10,000 total for WLS, including the hospital and surgeon fees. It's all contracted. Most insurers pay my surgeon less than $3k for his "cut". That's the way the health care system is, the cash payers pay the most.

Wow!  You put my mind at rest... Thank you!!!  I am still trying to get the paperwork aspect of this taken care of.  It's getting old.  Now they need a release form so they can request copies of my medical file.  I'm going to call today and find out what else is needed because I'm sure there will be more.  It's okay, because I am sorta scared about the surgery.  Were you?  I mean, I have a daughter who is going to be 17 in a couple weeks and outside of me and her, we have no family.  I was adopted/taken away and ward of the courts... daughter from traumatic cir****tances and so no father or extended in his direction.  It's just me and her... and as much as I want/need this... it's scary too.  I have always had a lot of stomach problems/gastrointestinal crap and they've had trouble diagnosing it.  They have a list of things and mostly nothing has worked.  I did have my gallblatter removed and that was significant as far as pain went.  Anyhow... do you think you'd do it again?  I know it's worth the risks and if I don't do this, I might not be around for my daughter... but it's scary.  I just wi**** were over already.  How long after the paperwork is finished does the surgery actually happen?  Did I read correctly that the surgery hapens first and THEN medicare gets a bill?  Like, there isn't preapproval or such?  And Medicare is the EASIER insurance?  SERIOUSLY?  If this is true... I am SO thankful for your help... you just erased half my stress!!!  Appreciate your help... and Gosh you look GOOD!!!!   I can't wait!!!

Medicare covers the following: - BPD/DS aka DS (Biliopancreatic Diversion with Duodenal Switch) (lap and open) - RNY (Roux-en-Y Gastric Bypass) (lap and open) - AGB aka Lap-Band (Adjustable Gastric Banding) (lap only)

Each procedure must be performed in Medicare-approved (as in Center of Excellence) facilities.  For a listing of them, click on this link: http://www.cms.hhs.gov/MedicareApprovedFacilitie/BSF/list.as p#TopOfPage

Medicare does not cover the following: - VSG (Vertical Sleeve Gastrectomy) (lap and open) - VBG (Vertical Gastric Banding) - AGB aka Lap-Band (Adjustable Gastric Banding) (open only) - Gastric Balloon - Intestinal Bypass

As for revisions, Medicare covers open and laparoscopic Roux-en-Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB) and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) if certain criteria are met and the procedure is performed in an approved facility.

Source: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=100.1&ncd_vers ion=2&basket=ncd%3A100%2E1%3A2%3ABariatric+Surgery+for+Treat ment+of+Morbid+Obesity Medicare does not pre-authorize any medical services that are considered "medically necessary".  For WLS, "medical necessity" is defined as follows: BMI of 40 WITHOUT any co-morbidities BMI of 35 WITH at least one serious co-morbidity (such as hypertension (high blood pressure), heart disease, diabetes (Type 2), and sleep apnea)

I have had several surgeries that were covered by Medicare.  None of them required any pre-authorization from Medicare.  Therefore, I was in the "express lane" each time, meaning that all my surgeries were scheduled much sooner than if others had to go through all those hurdles with their insurance companies.

To answer your own question, I am sure that Medicare works the same way as far as WLS goes. Hope this helps!

i have medicare also...with an advantage plan....you qualify under medicare rules without co-morbities if you have a BMI over 40....however i wouldn't worry about medicare i would try to find out what the criteria for Texas State Medicade is because medicade criteria is usually different than medicare and usually has alot more hoops to jump through. Here's what you need to know about medicare.  I would call my case worker or research online about my medicade...You can also ask your surgeon's office for help.  They would know where to tell you to turn to about medicade. Below is a PDF from CMS. (centers for medicare and medicade services)  http://www.cms.hhs.gov/Transmittals/Downloads/R931CP.pdf there direct website is www.cms.gov  it is a searchable site and may be able to help you on the medicade aspect of your issues.