Medicare requirements

I read on the boards here that Medicare requires: A BMI of 35 or greater with one comorbidity OR A BMI of over 40 and no comorbidities To get approved for the surgery.  I can't seem to find anything on Medicares website that says this.  I don't think I have any comorbidities (exept for MAYBE sleep apnea) but I do have a BMI of 46.   I am desperate to find answers on this. Jill

I am in Alabama, I was told on this board that medicare was already Pre-Approved. I attended my Seminar and was informed by my doc that I was Pre-Approved no 6 month diet just approved . There is no approval process. I just have to do his test that he requires.You will get alot that says different but the Lady on here that told me no approval process was right. She has worked for Medicare for 11 yrs.

Well, I went to my appointment and the doc's office here in Texas says that I do have to do a Dr. supervised 6 month diet.  Maybe it is different state to state?

Must be ? I don't have to do anything here but have the surgery. The only thing different is I have to stay overnite Medicare requires it for the Band.

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) 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 Hope this helps!

I am from Texas and have Medicare also. I went to the Dr.s Friday for my first consultation and I was told that I had to be on a 6 month physician-supervised nutrition/exercise program OR a multidisciplinary surgical preparatory regimen for at least 3 months. Medicare also requires an examination by a psychiatrist or psychologist experienced in the evaluation and management of bariatric surgery stating patient is an appropriate candidiate for the surgery. All this, plus the BMI of 35 with comorbidties or 40 without.

I also have Texas Medicare A&B and have been experiencing problems.  My BMI is was 51 when I started this quest and is now down to 47 after weight loss of 38 pounds (I think)... but now the surgeon is saying that I have no co-morbidities that qualify me.  I don't have high blood pressure, diabetes and sleep apnea.  I DO have weight bearing joint pain and have been taking large doses of percoset for more than three months now for chronic weight related back pain and have been diagnosed in past year with heapatic liver disease, which I think is the same as fatty liver disease, although I am not sure.  I have diagnoses of metabolic disorder which the doctor said was pre-diabetes and otherwise, I have nothing else.  I have been trying to find the website that lists the co-morbidities required, but have been unsuccessful.  I don't think it's true anymore that you just have to have a high enough BMI without the comorbidities, but I am so tired and frustrated because I have done the six month (actually it was a year) supervised weightloss physician reports, but the surgeons office is saying that I don't qualify.  How do I go around this?  Can I just go to a different surgeon?  I already have all the tests necessary: Stress test, sleep study, etc.  What about getting a letter and writing to Medicare?  I am on disibilty (though not specifically for weight reasons) but I know that with this surgery I would be able to work again and thus no longer need SSI/SS.  Please, anyone that can help... I NEED it.  I am so tired of this process, but I don't want to just give up.  I wonder also if I could talk to a lawyer... although the reality is, I cannot afford one.  I am on a fixed income.  Maybe some letters to the insurance?  Medicare?  Thanks in advance for the help... I am at the point of giving up.  I am so tired of fighting this.. it's been over a year already and I am thinking that it's never going to happen.  Thanks, Kim

I just don't understand this. I am a BMI of 42.6 with co-morbidities. My Doctor and The lady at the

medicare phone number told me, only 1 co-morbid needed and only a 3 month diet.  I got this information in Late May early June of 2008. I am in washington state but Medicare is a Federally funded Program. That's why there is only one Medicare Website, not split out by states. How can there be such a discrepancy.  I better not get a huge bill for this cause some yahoo told me the wrong info.  anybody know for sure?

I got turned down for the surgery early July from my surgeon.  They went to a conference in D.C. and went to Medicare CSMS (?) and told me that I had to have at least one co-mord. and my paperwork doesn't show any.  I think it was hypertension (with at least two failed medications to fix the problem) and diabetes (with THREE failed medications-that weren't working NOW), osteoporosis in knee bearing joint (that I couldn't fix through surgery because of weight) and I think there were a few more: oh, sleep apnea (must be using pap machine) and maybe a few more... but I have none of them.  They said that the hospitals were very strict and if you came in registered and they couldn't verify the co-morbid that they would send you home from there and cancel the surgery.  So my surgeon said they couldn't even get me in because Medicare isn't paying if you don't have documentation of those.  I have BMI of 57, without any of the extenuating things.  I mean... I can't function without 240 percocet a month because of the debilitating back pain (and I HATE to be on this much medication, but have such a high tolerance to drugs that I can't take anything less)... I've been trying to walk and workout but every time I get on a treadmill I get bone spurs on my heals of my feet that it puts me in hobbling mode for days/weeks.  It didn't look like I would EVER have all those things listed unless I got diabetes or something and had it for years without being able to control it.  That's what they said... diabetes not controlled by 3 types of medication... anyhow.  If your doctor and medicare said they'd cover it, you have at least one of the co-morbids that they listed and your surgeon feels comfortable going thru with the surgery.  It really is up to your surgeon because they don't bill medicare until AFTER your surgery.  You shouldn't worry because your surgeon is obviously fighting for you.  Mine just gave up.  I had over a year of doctor supervised: more like a year and a half... I'm never going to get this for me... but I'm thankful that at least some of the Medicare recipients are.  It sucks.  It could be MY specific surgeon too... not willing to do this for me because I pushed the envelope.  I think that he chose a ****ty time to decide because he strung me along for so long and didn't decide to refuse until after he'd seen me several times and took a few bucks off my insurance and even went so far as to get me on preop diet.  I feel like his office (Dr. Patel in San Antonio) were herding people in like cattle and no longer had an investment in people personally anymore.  It was all about the money... SHOW ME THE MONEY!!!  I don't care what anyone tells you about him... he was a crappy doctor.  I was already on the preop diet and waiting for a surgery date in the next week and then he just said "nope, we can't do this".  I'd been fighting for this and going through test after test after test (for over a year!!!) and seeing HIM... paying HIM!!! and then last minute, he says sorry.  HUGE LET DOWN!!!!  Your right that you don't want to get a huge bill from medicare, but you'd already have had the surgery and you'd be fighting from the other side by writing and appealing Medicare AFTER your surgery and already on the losing side of at least one battle.  I can't even TRY to fight medicare because my surgeon was a stupid yahoo that you mentioned you didn't want to get wrong information from.  I have been fighting serious depression because it's a HUGE let down after so much time and energy and money (and years) of expecting and waiting and planning and so forth.  They like "wrecked" my life for the time being and I'm trying hard to start over.  I want badly to write derogatory stuff about him so others can be weary of him... but figure it won't matter anyhow.  Sorry for the long and depressing response.  I'm sure your okay... and I am so happy for you.  Me... I'm all done with this fight.  I'm just going to take pills and keep trying to lose weight the way I've always tried and deal with those co-morbids if they come up.  I'll never trust another bariatric surgeon again after what this one did to me.  Good luck in Washington!  I lived there for awhile and it was beautiful!!!  I only hope for you the best... consider yourself lucky and blessed.  Kim

I am so sorry to hear what happen to you. I do however think that you should not give up. I cannot understand this as Medicare is a federally funded program. When you look at the website for information it is not broken out by state, when you call medicare they do not ask what state you are in.  For that reason I do not believe there are different rules for different states. You should call yourself and check. I called Yesterday to be sure I would meet the conditions. They read from thier computor what the requirments were and none of what you said was mentioned. Except having one co morb. If I were you I would call Medicare and see what they say. Then at least look for another surgeon and then look for another PCP one that will work with you to find at least one co morb. Not very christian like I know but I am frustrated and so not perfect. I am also glad you posted about your doctor other people should know. Maybe you should do your own post on how bad he was.