Revision with Medicare

Hi all. I'm new to this board, but I'm not new to weight loss surgery. I had a lap band placed in 2005 and never hit the sweet spot on fills. I initially lost about 30lbs only to gain back to my pre-surgical weight within a year in spite of many fills. I really didn't think there was any help out there for me until I heard about revision surgery going from lap band to gastric sleeve and that it was possible now under Medicare. I have several chronic conditions (diabetes that requires 5 insulin injections per day and rheumatoid arthritis that requires immuno-supressant injections weekly) that have landed me on disability and took me away from a career in nursing that I dearly loved. I started the process of meeting all the consult and testing requirements for revision and got a call yesterday that Medicare may not pay for the band to be removed. I feel the surgical coordinator didn't check things out thoroughly before I plowed through all these hoops to get to a surgical date of 9/2/14. I feel that she totally disregarded that I've got 2 of 3 required surgical visits done, a psych eval, and clearance from four specialists I see routinely. I still have to pay 20% of the bill when it's all said and done and I'm on a Social Security limited income.  I have a EGD in scheduled in a few hours after failing a barium swallow within drinking the first 30ml of fluid. She didn't know if this would qualify me. My question is: Have you had a revision done under Medicare and did they pay for all of it? If you've been down this route, could you please advise me. This surgery is a matter of life and death for me as my comorbidities are killing me, literally. Thank you in advance.

I'm no expert at this and you should really call your local medicare office to find out for sure. That said from the way I understand it medicare doesn't pre approve anything but as long as you meet their requirements they pay for it. I know for certain areas they do cover the sleeve now, as of last year I believe and if you are having that much trouble with the band they should cover removal. Talk to medicare yourself and then tell your insurance coordinator to contact them if neccesary. I know several people who have had bands removed and sleeve done with medicare. Good luck to you!!

Thank you for your response. The EGD today proved the band needs to come out. I did call Medicare and they advised the surgical coordinator call and talk to the claims department to see if a revision would be paid for and the requirements met. I'm still a bit upset that the surgical office asked me to pay for my band removal as if I were a private pay patient without fully exploring this with Medicare.

Medicare is much easier to work with than some insurance companies! They don't require pre-approval!!

Yes you would surely expect the coordinator to better informed about something as wide spread as medicare. I'm sure they must have done a few others before you. Now you know you will have to be a strong advocate for yourself with her or youu may get lost in the shuffle. Good luck to you!

Hi.....I just had a revision of my RNY on 07-23-14 and it was covered by Medicare.

Thank you for giving me some hope here. I feel I have the necessary medical documentation to justify my revision from a band to the sleeve. It is just a matter of getting this surgical coordinator to be willing to file this with medicare instead of demanding the cash up front for taking out the band or finding another surgeon who has had success with Medicare because I don't have the money up front to pay the amounts they require.

Can you tell us what requirements you had to meet?

At the time I started this process which was a year ago......my primary insurance (BSBC)  denied me saying it wasn't medically necessary. I resubmitted and they denied and came back and said I needed the 6 mos pgm, psych eval. Nut eval and other things. I started the 6 mos pgm and completed all the requirements.....mind you I am 5'2 weighed 208, had co-morbids of HBP, sugar, sleep apnea, asthma, hypothyroid, depression, osteopena . By the time I finished all the requirements it was 3 days prior to Medicare eligibility! It took Medicare 3 days to approve it.  I had my revision 4 days ago. It went really well....already tired of the clear liquids! Lol  I go see the dietician next week and was told my diet might be altered since nothing was done to my pouch! Also with Medicare you don't need pre approval as long as you meet their requirement! Call them and ask them the req because I had already completed everything including EKG, chest X-ray and upper GI and Blood work and evaluation by a cardiologist for clearance! Whew!!!

I had my RNY revision on the same date. How are you feeling? I was in the hospital until late Saturday afternoon. I came home with a drain in my side. I am starting to feel better but I feel like full recovery is going to be a long process. Would love to hear about your experience!