Final Binding CMS Decision (6/27/2012)

www.cms.gov/medicare-coverage-database/details/nca-decision- memo.aspx

VSG MEDICARE APPROVED!! (case per case basis determined by regional Medicare Administrative Contractors)

I Spoke directly with my Bariatric Director this afternoon about Medicare's VSG decision. She reviewed the CMS memo decision and agreed with my interpretation that this decision was a good one and coverage appears imminent. While the "fine" details for Medicare contractors (ie hospitals) have not yet been released (billing code, guidelines for submitting, etc) she did say everything looks like a go and I will be the first patient she submits for Medicare approval next month!

For those of you who have not yet had the opportunity to get a personalized nod of approval from your hospital, read this and you should feel better. This is a summarized analysis and decoding of CMS's VSG memo from The American Society for Metabolic and Bariatric Surgery (ASMBS). A true authority in all matters concerning Bariatric's.

asmbs.org/2012/06/access-to-care-alert-the-cms-final-decisio n/

At long last the wait is FINALLY over!

~Greg

Hello everyone-

I am a new member looking for some help and advice.  I am 28 years old and weigh 270lbs.  After several years (most of my life really) I have finally decided that surgery may be the best treatment for my struggle.  I contacted my insurance company and was a little confused.  The representative I spoke to said that my plan does not cover weight loss surgery but after asking several other questions she said it would take something drastic to get approved.  When I asked her elaborate she wouldn't. 

Does anyone know anything about Coventry and what they will and/or will not cover??  I'm pretty desperate right now and would love to see the light at the end of the tunnel. 

Thanks!!

Hello guys!

I am 2 years out and I want to have reconstructive surgery. Does anyone know how insurance can play a part in this. I live in Louisiana and have BCBS. thanks in advance!!!

It does sound like it's probably an exclusion, but I would be curious to know the context.  My insurance is worded similarly in the it says that it says surgery to primarily treat morbid obesity is not payable.  At first, it sounds like they won't cover it, but it goes on to say it is payable in the presence of morbid obesity and particular co-morbidities which will benefit from surgery treatment.  Can you copy and paste more of that section, possibly?

Disclaimer:  I don't work in insurance, but I was employed as a worker's compensation medical biller, and specialized in appeals.

I wanted to share some information I just gathered for myself in case anyone else on Medicare ever encounters the same situation when discussing payment criteria for WLS.  Because Medicare apparently uses coverage administrators, the requirements vary from state to state.  In my instance, I live in Tennessee, but I believe the patient advocate at my clinic was viewing information for Texas, which has slightly stricter and more specific qualifications.  This was a possible wall for me as I am depending on my recent diagnosis of hypertension to have WLS covered, but I have only tried one medication so far.  I've pasted part of the blog entry below.  You may view the blog entry in whole here.

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I went to the cms.gov Medicare Coverage Database and did a search of local documents for bariatric surgery.  I did one for Texas and one for Tennessee.  I confirmed that Texas' MAC (Master Administrative Contracter) is Trailblazer.  Their documented requirements for bariatric surgery do specify the following:

• - A body mass index of 35 or higher.
• - At least one comorbidity related to obesity.
• - Have been previously unsuccessful with medical treatment for obesity.
•  

Additionally, they define the comorbidities as:

• - Type II diabetes mellitus (by American Diabetes Association diagnostic criteria).
• - Refractory hypertension (defined as blood pressure of 140 mmHg systolic and/or 90 mmHg diastolic despite medical treatment with maximal doses of three antihypertensive medications). [emphasis mine]
• - Refractory hyperlipidemia (acceptable levels of lipids unachievable with diet and maximum doses of lipid lowering medications).
• - Obesity-induced cardiomyopathy.
• - Clinically significant obstructive sleep apnea.
• - Obesity-related hypoventilation.
• - Pseudotumor cerebri (documented idiopathic intracerebral hypertension).
• - Severe arthropathy of spine and/or weight-bearing joints (when obesity prohibits appropriate surgical management of joint dysfunction treatable but for the obesity).
• - Hepatic steatosis without evidence of active inflammation.
•  

A local search for Medicare coverage in my state showed that the MAC in Tennessee is Cahaba Government Benefit Administrators^®.  Their coverage documentation was a little more technical in terms, but I was able to read it.  (Thank you previous jobs in medical billing!)  It also states that bariatric surgery is payable under the specifications outlined in the National Coverage Database, which states:


"Effective for services performed on and after February 21, 2006, Open and laparoscopic Roux-en-Y gastric bypass (RYGBP), open and laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS), and laparoscopic adjustable gastric banding (LAGB) are covered for Medicare beneficiaries who have a body-mass index > 35, have at least one co-morbidity related to obesity [emphasis mine], and have been previously unsuccessful with medical treatment for obesity."


The appropriate comorbidities were listed in too great of detail on the local coverage documentation for Tennessee to be included here in this post, but ICD-9 codes 401.0-401.9 were listed, which is simple hypertension, and no previous treatment attempts were required.