Question:
I called Medicare and they said they do not pre-approve.

Has anyone had a problem getting Medicare to approve WLS? I really don't want to go through the whole preop process only to have them refuse to pay. I have Anthem BCBS as a secondary insurance. They said they will pay if Medicare pays. Thanks for any help you can offer..MJ    — Mary Jane C. (posted on August 27, 2003)

August 26, 2003
medicare does not pre-approve. My best friend had it in Nov. and the surgeon did all the testing and took her medical history (which he, not medicare) required and also turned in her medical history. When the testing was done she had her surgery and there was no problem with medicare paying. They used his records and her medical history(which was bad) and determined that she was medical mecessity (after her surgery was done.) All she had to pay was 800. to the hospital and 400. to the surgeon. None of it was upfront. They billed. Medicare paid nearly 30,000. dollars. I had surgery in feb with medicare as my secondary and also did not have a problem or have to have pre-approval. Medicare is federally funded so it is the same in all states. Some say they are now requiring a 5 year diet history but If they are, they have changed it. You shouldn't have a problem if you have co-morbs and are found by your surgeon to be medical necessity. Good luck.
   — Delores S.

August 27, 2003
Hi MaryJane, My mom has medicare too and they told her that they do not preapprove any type of surgery you hav edone that is just their policy. But htey are good about paying afterwards. My mom just had knee surgery a couple of years ago and they paid for everything including physical therapy afterward it was all done! So, now she is trying to have this surgery done and they told her just to go thru all of the process then after surgery her doctor will submit all of the papers then they should take care of it all! I also know other ppl who have medicare and wasn't preapproved beofer hand then had the surgery done and they paid for everything too! So, don't worry too much you should be fime but one thing you need to find a surgeon that will do the surgery before knowing if he'll be paid or not cuz some don't like doing it that way, but if you find the right one then they'll know that medicare will pick up the bill afterwards. So good luck to you and I hope this eases your mind some!
   — Melodee S.

August 27, 2003
Everyone is right Medicare doesn't pre-approve but usually will pay, the problem some are having where I live is that they don't pay anywhere near what they are billed so many of the surgeons won't accept it anymore, and some are down to one patient per month per doc.....I really feel bad for those that have to wait so long....Best Wishes!
   — Saxbyd

August 27, 2003
Thank goodness my doc accepts Medicare or I would still be pre-op. It is very true that medicare won't preapprove the surgery. As mentioned, the hospital submitts all the paperwork and then medicare either pays it or they don't. I just received some of the statements from medicare stating what they paid and boy they barely paid a third of the billing rate, but my surgeon's office new that ahead of time, so I guess I'm one of many of their charity cases. LOL. Now it time to wait and see if I'm going to receive more bills for my share. Some doctors don't bother to bill me for the co-pay and others do. It's wait and see now as to whether or not I'll have to file for bankruptcy. Oh well, at least I'll be a able to fit the regular size inmate uniforms. Good luck in your journey.
   — Rosa F.

August 27, 2003
I too have Medicare. I had my lap RNY June 11, 2003. Some of the major medical centers near me would not accept Medicare patients (their exact words--<i>they do not pay enough</i>. Their policy is to pay for bariatric surgery when the physican deems it necessary. My surgeon said "No problem, they always pay." And they did. My secodnary (Tricare) picked up the balance, so I had to pay absolutely nothing. Good luck!
   — Linda S.