newbie with medicare/medicaid

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).

Medicare will cover you for WLS as long as  your BMI is > 35 have at least one comorbidity and you get surgery at a Bariatric Surgery Center of Excellence


VIII. CMS Analysis

Medical treatment for obesity includes dietary manipulation, behavior modification and medication. These therapies have been tried individually and in combination, but with only limited long-term success. However, based on the lower risk-benefit ratio for medical treatment, we believe it should be routinely attempted and shown to be unsuccessful before considering a patient for bariatric surgery. There are no consistent standards in the literature regarding length of a medical treatment trial and, therefore, we are unable to specify a specific time interval. A number of trials and guidelines recommend 6 to 12 months and we believe that to be reasonable.

 

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.

Medicare does not specify a specific time frame for medical weight management. They say it's customary for some surgeons to require 6 -12 months, which they agree with but they do not state a time frame specifically. I think that's up to your surgeon.


I don't have Medicare but from reading their website it sounds like once you are considered a candidate for WLS your doctor can just pre authorize you themselves and they don't have to go through Medicare. I'd take the medicare guidelines in to your doctor and see if they can't help you speed the process along. Best of luck

https://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?from2=viewd ecisionmemo.asp&id=160&

Edited to add: have you looked into the DS (duodenal switch) or BPD-DS, it is a covered benefit with Medicare and has the best long term results for weight loss and maintainence. You should check out the DS board while you're still researching your options.