Medicare guidelines?

What are the Mcare guidelines as far as any documentation needed or is there any?  Thanks, Terry

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.asp#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_version=2&basket=ncd%3A100%2E1%3A2%3ABariatric+Surgery+for+Treatment+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)

Hope this helps!

Thanks so much for all the info.  So when it says they do not preaurhorize, what does that mean.  My husband's BMI is around 56 and he has lots of co-morbidities. 

Will he need a letter of medical necessity or a referral letter? 

I am trying to get mine covered by BC and I know I am having to do the 6 months of supervised diet, 5 years of weights and etc. 

Just want to see for sure what he will need.

Thanks, Terry

So when it says they do not preaurhorize, what does that mean. 
It means that the physician does not have to contact the insurance company to authorize certain medical services as long as those are considered "medically necessary".  "Medically necessary" was already explained in my earlier posting on this thread. 

Will he need a letter of medical necessity or a referral letter? 
That's something that you would have to ask the surgeon's office.  The surgeon may or may not require a letter of referral from the PCP.

Is there anything written that tells you qualification timeline?  Meaning, I was told that I have to go to six consecutive meetings before I get my surgery date?  I tried to look up information on the medicare website but could not find any that tells me the guidelines.  Any help would be greatly appreciated.

Lorrie

Medicare does not require any physician-supervised diet.  Those are not beneficial to patients.

All you have to do is to meet the BMI guidelines as noted in my earlier posting on this thread.

Are you truly with Medicare or a Medicare advantage plan? The reason I ask is that I am disabled and have a Medicare advantage plan through United Health Care and I am being screwed over so badly I don't know what to do. Not only will they not pay for the surgery I am being told they will not pay for all t he testing I had done.  This ia amounting to thousand of dollars I don't have because I am disabled.  Please get everything in  writing before you go any further and make sure they will pay fo r everything.  I hope you have more luck an d success than I did.

This is a straight Mcare plan so I hope it goes through.  I will let you all know when we find out.  Have to get the psych eval done first then will be submitted.  Thanks, Terry

Please I beg you make sure that the Psych eval will be paid for before you get it done otherwise you may be stuck with having to pay it yourself.  I am so mad about what happened to me I am spitting nails. The Medicare advantage plan was suppose to offer me more than Medicare.  Oh yea it offered me more, More headache, More strsss More frustration.  Just what I wanted.

 As far as the Medicare requirements (non-Advantage), is the 6 month supervised diet required or not?  I keep hearing different things from different centers.

I'm so hoping not, because I finally found a doctor who states that the supervised diet is not necessary for Medicare which would mean being able to get the surgery sooner than later.