Medicare covering sleeve..or not.

I spoke with my patient advocate yesterday and she said that Medicare does not cover the sleeve. I called Medicare with the procedure code and they said they do. Now it is an uphill battle with my doctor. Has anyone had the sleeve and had it paid by Medicare?

Medicare did approve the sleeve. I do not have medicare but my insurance said they approved the sleeve because medicare approved it and gave it a procedure code.

I think it's a fairly recent thing. I think I've seen a few posts on here in the past couple months saying they just started covering it.

Julie,     I had the sleeve on Jan 25, and Medicare paid for it...   Medicare also paid for my lap band in 2009, (which failed)  and was removed in March 2012.

I'm so aggravated. The docs office said since they did not get paid for five surgeries by medicare LAST year, they are going to re-bill for them and see if medicare covers them. Until, then they won't touch me. Im just so frustrated because I spoke with medicare yesterday. Gave the the procedure code and they said that they DO pay it. My docs office called and they told them the SAME thing. Just because they didn't get paid last year, I am paying the penalty for it. I don't know what to do. I cant make them do it. I don't want to try a new doctor because this guy is supposed to be the best in the city. I just don't know what to do now.

They're not going to get paid for any surgeries before February 14th, 2013 according to the documentation.  That's absurd.  Part of being the best doctor is having good staff!  I ended up driving 2 1/2 hours away for my surgery.  If you can't get anywhere with them, it may be time to look elsewhere.  Best wishes to you!

There are still some rules that must be followed .  The most recent thing I could find on the CMS web site was this page:

http://www.cms.gov/medicare-coverage-database/details/nca-de cision-memo.aspx?NCAId=258&NcaName=Bariatric+Surgery+for+the +Treatment+of+Morbid+Obesity&CoverageSelection=National&KeyW ord=obesity&KeyWordLookUp=Title&KeyWordSearchType=And&where= index&nca_id=219&basket=nca*3a$00397N*3a$219*3a+for+Diabetes *3a*3a*3a$5&bc=gAAAABAAIAAA&

which indicated BMI, cormorbidities, as well a notating the medicare contractors within jurisdictions may determine coverage -- so it's not clear if the jurisdictions still have some ability to OK or deny, even if you fall within the criteria.  Also, see below. If your doc doesn't practice at a Medicare approved center of excellence, Medicare will not cover it.

So I suggest you call Medicare back and ask questions specific to your weight and comorbidities and find out where the Centers of Excellence are in your area.

 

Where Can I Find a Doctor Who Does the Surgery?

Ask your doctor for recommendations for a local Medicare-approved center. The Centers for Medicare & Medicaid Services (CMS) website has a complete list of approved centers for bariatric surgery at www.cms.gov.

Other important things to know:

• Medicare will not pay for the surgery unless it is completed at a Medicare-approved "Center of Excellence" for bariatric surgery.

Medicare did approve coverage of the sleeve, however, they leave the final determination of coverage up to the Medicare Administrative Contractor (MAC) in your state.  They can decide whether or not it is covered, and what the pre-requisites are for surgery.  This is called a Local Coverage Determination (LCD), and it means that it varies state to state, because there are multiple MACs.  It is also important to know that there is not pre-authorization for the surgery.  Medicare will not guarantee payment, it is just up to the surgeon to determine that you do meet the criteria outlined for surgery satisfactorily and to do the surgery believing that Medicare will agree and pay.

I had the surgery about three weeks ago in Tennessee and was among one of the first Medicare VSG patients for my doctor.  I did a quick search for you and looks like the MAC for Nevada is Palmetto.  Please do not take what I say as fact, this is only what I find with my own research and I am not an expert.  However, it looks as though VSG is covered in Nevada as of February 14th, 2013 for patients 65 and younger.  Here is an excerpt from the LCD on cms.gov:

Palmetto GBA is concerned that there are no randomized controlled trials (RCTs) that evaluated adults ≥ 65 years, few large scale trials on stand alone LGS and few, if any, long term trials. Palmetto GBA medical directors have also discussed the surgery with subject matter experts in our jurisdiction. Given the above lack of a large body of peer reviewed data, Palmetto GBA will cover laparoscopic sleeve gastrectomy only when all of the following criteria are met:
 

• Patient is under 65 years of age.
• Patients has a BMI ≥ 35.0 kg/m² (Class II or Class III obesity)
• Patient has at least one co-morbidity related to obesity
• Active participation within the last 12 months prior to bariatric surgery in a weight-management program that is supervised by a physician or other health care professionals for a minimum of four consecutive months. The weight-management program must include monthly documentation of ALL of the following components:
  • weight
  • current dietary regimen
  • physical activity (e.g., exercise program)

Physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement.

• A thorough multidisciplinary evaluation within the previous six months whi*****ludes ALL of the following:
  • an evaluation by a bariatric surgeon recommending surgical treatment, including a description of the proposed procedure(s)
  • a separate medical evaluation from a physician other than the requesting surgeon that includes both a recommendation for bariatric surgery as well as a medical clearance for surgery
  • clearance for bariatric surgery by a mental health provider including a statement regarding motivation and ability to follow post-surgical requirements
  • a nutritional evaluation by a physician or registered dietician
• LSG is furnished in a CMS approved bariatric facility.

The information above must be documented in the patient's medical record and available on request.

In my experience, it does take a while for billing at doctor's offices to know about these changes, and you just have to keep checking it back.  It might be a good idea to print out that page and send it do your surgeon's office.  I hope this helps!

Bless ALL of you for your taking the time to help me. I am so humbled by everyone here. I will forward the info to my doctors office mgr.

Sooooo after great thought and reflection, I am probably going to switch doctors. I read the CMS website and it says I will need 4 months of doctor guided dieting. I've been dieting my entire life LOL. I wonder if there is any way around this. Any ideas? I am so desperate to get started already. I have had 4 major spine reconstruction surgeries and I seriously need to get rid of the weight I have gained since I had them.  Sometimes I feel like the extra weight is crushing my arthritis ridden bones. I was DX with Osteoarthritis at 18 and am now almost 52. It has really taken its toll on me and I am ready to live a different life with less pain. The idea of having to wait another 4 months is devastating to me. The crappy thing is in addition to Medicare I have BCBS which does not require a 4 month wait. But, if I use them only, I will have a 2000 dollar co-pay which I cannot afford. Blech.