Medicare

hjmomma
on 7/11/07 6:23 am - SPARTA, TN

I am planning on having the gastric bypass done sometime after the first of next year. what i need to know is will medicare pay for it without a bunch of hassels or what kinda hoops am I gonna hafta go through with them? Does anybody know? I am presently waiting for a disability hearing which won't happen until around the end of this year. Once I get my disability and get my medicare and medicade cards I need to have this surgery done. Can anyone tell me what I am gonna have to go through with medicare?

AngieCut
on 7/11/07 7:39 am - Old Hickory, TN

I have disability I'm legally blind in both eyes even with corrective lenses so I have the AmeriChoice TennCare plan B. This first list is from the one I have and the second list will be labeled. Please forgive any spelling mistakes I was trying to copy the information from papers with small font so I wasn't paying attention to the screen just the paper that I copied the information from. HOPE THIS HELPS!!! Here are the requirements for the AMERICHOICE TENNCARE PLAN B Insurance. *BMI Exceeding 40 for at least 5 years or: *BMI greater than 35 for at least 5 years in conjunction with any of the following sever co-morbidities: coronary heart disease, type 2 diabetes mellitus, medically refractory hypertension (blood pressure >140mmHg systolic and/or 90mmHg Diastolic despite optimal medical management), clinically significant obstructive sleep apnea, or severe respiratory insufficiency. (NOTE: Clinical evidence does NOT support the use of bariatric surgery to treat gynecological abnormalities, osteoarthritis, gallstones, urinary stress incontinence and other obesity associated diseases that generally do not lead to widespread or life threatening consequences). *Patient has completed growth, 18 years of age or documentation of completion of bone growth for primary procedure (NOT to exceed age 65). *Documentation in the medical records of participation in a physician-supervised nutrition and exercise program for a cumulative total of six months within the last year prior to the surgery, and at least three consecutive month's continuous participation prior to the date of surgery. Member's participation in a physician-supervised nutrition and exercise program must be documented in the medical records by a physician who supervised the member's participation; either PCP or requesting surgeon would qualify. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician. medical records to support prior nutrition and exercise program participation should be available upon request. Program with a loss of 5% of the patient's initial body weight and ability to maintain this weight for 6 months prior to the authorization request. *Documentation of incapacitation to perform the activities of daily living due to obesity (examples: wheelchair or walker use, etc.) *Pre-operative psychological evaluation and clearance is required of members who have a history of severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications in order to exclude members who are unable to provide informed consent or who are unable to comply with the pre and post operative regimen. * Contraindications-Patients who are not likely to be able to comply with a strict life long dietary regimen, abuse drugs or alcohol, have multi-system organ failure, are actively growing, have liver, kidney, or gastrointestinal disease or engage in regular binge eating are contraindicated for bariatric surgery. *Gastric bypass and Lap-band procedures are covered (NOTE: Lap Band & Revisions: unless Tenncare contacts our Center requesting surgery for you, Tenncare requires that Lap Bands and Revisions of previous weight loss surgery be preformed by Tenncare surgeons. Please contact Tenncare to discuss.) NOW FOR THE TENNCARE BLUECARE, SELECT and AMERIGROUP Here is the requirements for these: *BMI of 35 to greater with at least 2 of the following conditions: hypertension, hyperlipidemia, diabetes under active treatment, coronary artery disease or cardiomyopathy, disabling musculoskeletal dysfunction, and sleep apnea or pulmonary insufficiency OR: *BMI of 40 or GREATER *Diagnosed as morbidly obese for AT LEAST 5 years or longer. *Letter from primary care physician recommending Bariatric surgery (physician must document in letter 5 year history of weights that diagnoses the patient as morbidly obese (Get medical records but they do not have to be sent to Tenncare, only letter needs to be sent for approval but doctor must have them on record incase of lawyer interactions). *Documentation of incapacitation to preform the activities of daily living due to obesity (examples: wheelchair or walker use, etc.). *Medically supervised diet or Tenncare Weigh****cher Program with a loss of 5% of the patient's initial body weight and ability to maintain this weight for 6 months prior to the authorization request. *Willingness to comply with pre and post-operative treatment plans including nutritional, behavior and exercise counseling, and lack of a pregnancy during the rapid weight loss phase (must be documented that candidate has no barriers in the psychological evaluation and physician notes) *Consult with surgeon *Psychological evaluation *18 years of age or older (unless with special consideration). *Gastric Bypass and Lap-Band procedure is covered.

Angie

Sandy V.
on 7/11/07 2:34 pm - Brownsville, KY

RNY on 09/09/08

I also have Medicare, but I am in Kentucky, and will be going to Centennial and Dr. Dyer for wls. This was sent to me by their insurance specialist. This is the new criteria for surgery. You do not need pre approval with medicare, but you do need to meet this criteria in order for Medicare to pay for the surgery. Good luck, and I hope this helps. Belinda. These are the Medicare requirements for the surgery; please take this to your primary care doctor to show documentation.

Medicare

· BMI of 35 or greater with one of the following life-threatening or disabling co-morbid conditions: poorly controlled type II diabetes, poorly controlled hypertension, poorly controlled dyslipidemia, severe cardiopulmonary disease (e.g. coronary disease, CHF, asthma, COPD, pulmonary hypertension), obstructive sleep apnea, severe arthropathy of weight bearing joints or pseudotumor cerebri

· Surgery is medically appropriate for the patient

· There is documented evidence of repeated failure of multiple attempts (usually 3) to lose weight on a supervised non-surgical management weight loss program (e.g., diet, exercise or drugs). It would be expected that a weight loss program would consist of compliance with a physician directed program for at least a consecutive 6 month period without significant gaps. Monthly documentation of the beneficiary’s compliance should include: **vital signs to include weight, current dietary program, physical activity/exercise program, behavioral interventions, consideration of or use of pharmacotherapy with FDA- approved medication, if appropriate

· Psychological evaluation (and counseling)

· Treatable metabolic causes for obesity (e.g., adrenal, pituitary or thyroid disorders) have been ruled out or if present have been maximally clinically treated if present

· Surgery performed at ASBS Center of Excellence

**All documentation must be written in the medical record monthly (diet, exercise and behavioral interventions)

hjmomma
on 7/15/07 3:34 am - SPARTA, TN

Thank you Angie. This has helped me alot. I will keep this in my archives and refer to this when the time comes. I am currently on a low protein diet that my daughter has put me on to lose some weight before this surgery. She has helped her 500 lb. sister lose weight and she is down to about 150 lbs. If it can help her it can help me.

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