Question:
Has anyone been approved by medicare?

I have an appt. with the surgeon next week. He is a medicare approved doctor and accepts medicare. I called medicare and they said there is no Pew-approval. You have to wait until the surgery is over and submit it. At that time they will tell you if it is approved or denied. I can't take that chance. My secondary insurance (BC/BS)said they only pay if medicare pays. Anyone had any experience with this?Thanks..MJ    — Mary Jane C. (posted on July 24, 2003)

July 24, 2003
Yes, medicare will pay for ryn. I know several people who have had it done this way. It does state has to be medically necessary. Good Luck. Mary
   — mary K.

July 24, 2003
MJ, I am on Medicare. My BMI was 51 going into surgery, and Medicare took care of it! My secondary picked up the balance..no problems at all.
   — Linda S.

July 24, 2003
I am preop and on medicare. I dont know why they would say you need to have the surgery before they will pay. I have waited for about 4 months now and have another 2 1/2 to go till surgery. I know you will prevail in you journey keep posting when you have a question and let us know how everything is going. You can email me as well [email protected] Bye Dan
   — D P.

July 25, 2003
It is true that medicare does not preapprove wls.This is a fairly new change in policy....I have medicare as my primary insurance and state medicaid as my secondary.......This is how it works....I found a surgeon who took medicare and I had my surgery june 9th then they submitted all my info to medicare for payment...If medicare thinks it was medically necessary then they will pay their portion which is 80%....Ordinarily I would then be responsible for the remaining 20% but since I also have a secondary insurance that is state funded I won't have to pay the leftover 20% because if medicare says the surgery was medically necessary then my secondary will have to pay the remainder.Alot of people are under the misconception that if they have medicare and also a secondary insurance that they also have to get approved through their secondary and that is not always true.
   — jennifer A.

July 25, 2003
Medicare will definitely not do a pre-determination before surgery (any surgery) is done. Once the surgery is done, the claims are submitted and Medicare then requests medical records from the surgeon so they can determine whether they think the surgery is medically necessary. If your surgeon does surgeries on enough Medicare patients, he/his staff knows Medicare's requirements for medical necessity and should be able to tell you before the surgery whether they feel you fall within the criteria. However, they will most likely ask you to sign an ABN (Advance Benefit Notice) form which states that you understand that you will be responsible for paynent of the surgery fees if Medicare denies the claims. Also, the insured should always contact their supplemental insurance and ask whether they will pay the 20% after Medicare automatically or do they require a pre-determinatioh to be done so that they can determine medical necessity themselves before the surgery is done. Every supplemental is different.
   — Bonnie