Question:
Need Info on INSURANCE

A Friend has Tri care and Medicare Ins. shes morbisly obease Doc says she can have the surgery But told her that medicare would not pay for it... What does she need to do? She is so huge she is going to die if she dont get help.. Thanks for leading me in the right direction... thanks    — Flo (posted on March 31, 2006)

March 31, 2006
Medicare coevers WLS. Her surgeon may not be on the approved list, so they will not pay for him to do the surgery. Here is the Medicare statement: "Decision Summary The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is adequate to conclude that 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), are reasonable and necessary for Medicare beneficiaries who have a body-mass index (BMI) > 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. 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). A list of approved facilities and their approval dates will be listed and maintained on the CMS Coverage Web site at www.cms.hhs.gov/center/coverage.asp, and will be published in the Federal Register. The evidence is not adequate to conclude that the following bariatric surgery procedures are reasonable and necessary; therefore, the following are non-covered for all Medicare beneficiaries: open vertical banded gastroplasty; laparoscopic vertical banded gastroplasty; open sleeve gastrectomy; laparoscopic sleeve gastrectomy; and open adjustable gastric banding. The two non-coverage determinations in the National Coverage Determination Manual (NCDM) remain unchanged - Gastric Balloon (NCDM Section 100.11) and Intestinal Bypass (NCDM Section 100.8). Modification of the current policy on obesity, found in section 40.5 of the NCDM, will include a reference to the covered surgical procedures and will merge the obesity policy with the final bariatric surgery policy. The modified obesity policy will read as follows (emphasis added to the new language within the policy): Obesity may be caused by medical conditions such as hypothyroidism, Cushing's disease, and hypothalamic lesions or can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension. Certain designated surgical services for the treatment of obesity are covered for Medicare beneficiaries who have a BMI > 35, have at least one co-morbidity related to obesity and have been previously unsuccessful with the medical treatment of obesity. Treatments for obesity alone remain non-covered." Source:http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=160 Find her a surgeon at a Center of Excelence and let Tri Care and Medicare figure out who pays for what. Best wishes to your friend. Joshua
   — nursenut

March 31, 2006
As stated in the first post medicate does pay for 3 types of this surgery GB, LB and DS. Here is there website where you can find by state who medicare authorizeds to do the surgery: medicare.gov. Look on the left hand side for "Provider Information" click on it. Then go to Medicare on right in blue and then scroll down and click on approved facilities.
   — ccstann

March 31, 2006
I dont' know about the medicare but I have Tricare Prime and it completely paid for my surgery. Good Luck.
   — HubbysBrat

March 31, 2006
tricare will pay for gastric and not lapband. as long as she qualifies....
   — tinaharing

April 1, 2006
I live in Alabama. I have Medicare and Tricare Standard. Medicare paid 80% of the surgery and Doctor Bills and Tricare Standard paid the other 20%, I never had to pay the first penny. Tell your friend to find another doctor!!
   — cindirella