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
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