MEDICAID AND MEDICARE SURGEONS LIST!

Hi there...... I am a "hoping" for person, hoping to get surgery that is..... right now I am completing one of the pre-requisites required by Medicaid for approval.... 6mo Dr. supervised diet.  I have done alot of checking into this since I am on Medicaid. This is from one of the Medicaid Bulletins (online at http://www.ncdhhs.gov/dma/bulletin/1005bulletin.pdf with additional information found in the full "manual" on Obesity treatment at http://www.ncdhhs.gov/dma/physician/1a15.pdf  )

Gastric Bypass Prior Approval Documentation

 

 

As indicated in Clinical Coverage Policy #1A-15, Surgery for Clinically Severe Obesity, all of the following medical documentation and information must be included with prior approval requests for surgeries for clinically severe obesity:

 

1.        Documentation of a continuous six month period or longer of all medical treatment modality

 

therapies attempted by the recipient under the supervision of a physician or in an organized

weight loss program to reduce weight, the duration of each therapy and the results of each

treatment. 

 

2.        Documentation of the recipient’s weight for three separate years.

 

3.        The recipient’s present weight, height, skeletal frame, body mass index and gender.

 

4.        Medical history of all of the recipient’s diagnoses such as hypertension, heart problems, pulmonary problems, arthritis, joint pains, back problems, etc.

 

5.        A complete listing of all the recipient’s medications.

 

6.        Blood pressures, fasting blood sugar levels, pulmonary study results, orthopedic x-ray reports, etc.

 

7.        Documentation that all correctable causes of obesity have been ruled out with test results of laboratory tests performed, such as thyroid panel, etc.

 

8.        Documentation of a psychological evaluation assessing the recipient’s suitability for surgery and his/her ability to comply with lifelong dietary changes and medical follow up.  Components of such an assessment should include:  levels of depression, eating behaviors, stress management, cognitive abilities, social functioning, self-esteem, personality factors or other mental health diagnoses that may affect treatment, readiness and ability to adhere to required lifestyle modifications and follow up/social support.

 

9.        Documentation of a fully developed, 5-year psychosocial, nutritional, and activity-based follow-up plan.

 

10.    Certification that the recipient has been informed about all surgery risks, surgery sequelae, the need for extensive follow-up care, expectancy of weight loss and a signed statement that the recipient has been informed of the risks and results and still desires a surgical procedure.

 

11.    Description of the type of gastro-bariatric surgery planned and CPT code that describes the surgery planned.

 

An increasing number of requests have been submitted without the required documentation of a

 

5-year follow-up plan and a statement signed by the recipient certifying that he/she has been informed of the risks and results of the surgery and still desires the procedure.

 

Prior approval requests without all of the required documentation listed above will be returned to the provider.

 Please refer to DMA’s web site at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm for a copy of clinical coverage policy 1A-15. As well, my therapist has connected me with a surgeon (can't find his name this minute) and they informed me that the hospital in Franklinton, NC is undergoing the process to become a COE hospital ...... Yea me!! Since I live in Wake Forest and that would be soooooo Convenient for me. 

I just spent a little bit of time looking up about a Panniculectomy (form of tummy tuck), and found that this is also possible to be covered by medicaid.  According to http://www.ncdhhs.gov/dma/physician/1a10.pdf   sooooo...... now to find Plastic Surgeons who accept medicaid (well, I still have yet to get my RNY surgery so I am not in any hurry..... LOL.... still have to lose the weight)... but I already know I have such a flap now from my last pregnancy I cant imagine how bad it will be after I lose the weight.

I just had gastric bypass by Dr. DeMaria at Durham Regional in the Duke Weight Loss program on April 29, so I know they do accept Medicare.  Call Medicare direct and they will tell you what they require.  I was told I had to do a 6 month doctor supervised weight loss program by the Duke Weight Loss Center, which I did with Optifast.  Medicare would not pay for this Optifast program since the only doctor I could find did not accept Medicare.  I did write the $3500 expense of Optifast off of my taxes.  Anyway, Medicare said they did not require the six month weight loss prior to gastric bypass surgery.  I am glad I took off 90 pounds before the surgery but look in to it more careful that I did and do take everything with a grain of salt you are told by DWL.  I am happy with my surgery and Dr. DeMaria was great.  Other things left a lot to be desired.  I can be contacted at [email protected]   for more insight.

Hello Everyone:

 

I detemine Medicaid eligibility in NC.  I have had numerous clients who had the surgery and Duke excepted the Medicaid.  Medicaid does require a 6 month weight loss program supervised by your doctor. 

 

hope this helps.....and best wishes.   

 

Jonelle.....surgery date 08/11/2008

Dr. Naziri with Southern Surgical Associates in Greenville also accepts Medicaid. I just got approved.

 I am on Medicare and for sure understand my surgeon handles medicaid as well. He is out of Atlanta so living in western NC it was just about the same distance if I had gone to the center of the state. Dr. Michael Williams who does his surgery out at Emory John's Creek in North Atlanta (trust me its more like the Hilton than a Hospital is a center for excellence for Medicare. My up front expense whi*****luded the three days at the hospital was about 1600 dollars. I had to pay up front for the assisting surgeon and three days non medicare adjustment for the room and facilities. Dr. Williams is highly trained and his former partner James Champion is head of the Bariatric Surgeons board. I found the whole experience other than the initial pain of the surgery to be top notch and only three hours from home near Bryson City, NC. I have Humana medicare and i think they threw a party when I asked for the surgery just so they could get out of having to pay out the nose for my co morbid obesity problems. Please if you will add Dr. Williams to the list he is worth the trip. 

Medicaid has changed their requirements and the covered operations has been expanded to include the band and DS. 

www.ncdhhs.gov/dma/physician/1a15.pdf

You can take Frye in Hickory off this list.  I just went through a week of craziness trying to get all my papers to them only to have them call and tell me they don't take medicaid.