Medicare?

beemerbeeper
on 6/2/09 3:53 am - AL
I have only Medicare.  No secondary.  Just plain old Medicare.

I've looked though about 12 pages of posts on this forum and see no reference to Medicare.

Does anyone know what Medicare will cover?

Becky in NC
sunshine86
on 6/2/09 9:50 am, edited 6/2/09 9:51 am
Vicki Browning
on 6/2/09 3:38 pm - IN

Here is a link for what medicare approves

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5013.p df

If approved you would be responsible to the part a deductible for the inpatient stay and your doctors , anesthesiologist and surgeon after med b dedictble then you would be required to pay the 20%

(deactivated member)
on 7/9/09 8:23 am - KY
SOMEONE SAID DR. JOHN HUSTED WILL NOT ACCEPT THE MEDICARE 'ASSIGNMENT'..I GUESS THAT IS WHAT THEY WILL OFFER-AMOUNT.  SOMEONE SAID IT WAS ABOUT 7,000 TO HIM BUT THAT THE HOSPITAL WILL TAKE THE MEDICARE.  I HAVE PLAIN OLE MEDICARE PLAN A AND PLAN B.  SO I AM CONFUSED AND TRYING TO FIND OUT WHAT PEOPLE'S OUT OF POCKET EXPENSES ARE..
Vicki PNW
on 6/7/09 11:08 am

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 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)

Hope this helps!

Vicki

DS (lap) with Dr. Clifford Deveney. Cholecystectomy (lap) with Dr. Clifford Deveney 19 months post-op.

Has not weighed myself since 1/2010.  Letting my clothes gauge my progress instead.

beemerbeeper
on 6/7/09 11:37 am - AL
Vicky,

Thanks so much.  I had learned the first part (which procedures that Medicare covers) but I had not yet learned that they don't pre-authorize "medically necessary" or what "medically necessary" means in this situation.

So with my BMI at 39.5 and hypertension I should be good to go? 

Then I will just have to follow the surgeon's protocol in terms of jumping through hoops?

That sounds GOOD to me!!! 

I am attempting to jump thru my surgeon's first hoop on Tuesday:  making sure my pcp will agree (in writing) to provide all non-surgical follow up care.  I bet she is going to take every advantage of this new found power over me and make me have very damned test there is to take.  Dear God.  It will be awful.

Becky in NC
Vicki PNW
on 6/8/09 9:29 am
"So with my BMI at 39.5 and hypertension I should be good to go?"
Yep!

"Then I will just have to follow the surgeon's protocol in terms of jumping through hoops?"
And Medicare's too!  Each surgeon has his/her own requirements and their mileage may vary.

Best of luck!

Vicki

DS (lap) with Dr. Clifford Deveney. Cholecystectomy (lap) with Dr. Clifford Deveney 19 months post-op.

Has not weighed myself since 1/2010.  Letting my clothes gauge my progress instead.

beemerbeeper
on 6/8/09 11:50 am - AL

I received my surgeon of choice (Smith in Atlanta) application packet today.  It isn't too bad, there are only a few things I have to guess at.

So we shall see.

Becky

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