Hi all,

I have an insurance question. My insurance requires a 6 month supervised diet or a multi-disciplinary surgical preparatory regimen for 3 months with certain criteria’s met. I am doing the 3 month program in my state where they think I am having one of their surgeries they offer which I am not. I am having the ds surgery which they don’t  do here or really anywhere near me. I guess what I’m asking is after making it  through all the criteria should I continue through this entire program right through to the surgeon (which I have not yet met) and let them approve it, then go to my DS surgeon’s office and see if they can get that one approved afterwards? I have one more Nut appointment left then all my steps for the insurance has been met the only thing I’d have to left to do would be to meet the surgeon and let them know what surgery I wanted then they would submit the approval. There is no way I can do all this from so far away from the ds surgery. Has anyone else been through this or any suggestions? I have aetna  insurance.

 

Sorry if this is confusing I found it hard to explain.

 

Thanks,

Trish

 Has anyone been approved without having the 6 month dr. supervised diet?  I am scheduled for VSG on 8/13 and seeing the GP that my dr recomended for the first time tomorrow.  I am 30 yrs old, 5'11' and 265 lbs.  I've also been diagnosed with sleep apnea.  The insurance coordinator says that I have excellent insurance and is very optimistic that insurance will go through without a problem. But everything I'm reading seems to say that you need 6 months of a supervised diet.  

Look at Ready4aChange.com

CMS has released a memo regarding Medicare's decision for coverage of VSG.  They will not include it in the NCD (National Coverage Determination), rather they will leave it up to the MACs (Medicare Administrative Contractor), which varies from state to state.  If you don't know which contracter you are under for Medicare, you can find out from the CMS web site by searching the local coverage documents, or I found a convenient directory on a clinic's web site, which I hope they won't mind me linking.

I don't know how wide-spread this is, but one particular hospital in my town uses a different MAC from the one that administers my state, so if you find your state's MAC now covers the VSG, it may be important to make sure your local clinic also performs it for Medicare patients.  I attempted to see if VSG is now covered in my area, but I saw that the local coverage documents had not been updated since 2010, so I imagine it will take a little while for the MACs to make their own determinations about the VSG and update their coverage.  If this is confusing information, I would be glad to answer questions to the best of my ability regarding MACs, CMS, etc.  I've been a medical biller in the past, and have done a fair share of my own research for bariatric surgery.

Here is the an excerpt from the Memo:

IX. Conclusion

The available evidence does not clearly and broadly distinguish the patients who will experience an improved outcome from those who will derive harm such as postoperative complications or adverse effects from LSG. However, taking into consideration the seriousness of obesity, the possibility of benefit in highly selected patients in qualified centers, we believe that local Medicare contractor determination on a case-by-case basis balances these considerations in the interests of our beneficiaries.  Our local contractors are in a better position to consider characteristics of individual beneficiaries and the performance of eligible bariatric centers within their jurisdictions. Therefore, Medicare Administrative Contractors acting within their respective jurisdictions will make an initial determination of coverage under section 1862(a)(1)(A) and we are not making a national coverage determination under section 1869(F).

Medicare Administrative Contractors acting within their respective jurisdictions may determine coverage of stand-alone laparoscopic sleeve gastrectomy (LSG) for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries only when all of the following conditions A-C are satisfied.

1. The beneficiary has a body-mass index (BMI) ≥ 35 kg/m²,



2. The beneficiary has at least one co-morbidity related to obesity, and



3. The beneficiary has been previously unsuccessful with medical treatment for obesity.

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This is progress!

Well I've already started the process of telling the doctor what I wanted and doing the supervised diet. I just don't want to get disqualified from receiving PCIP insurance because I've already started the process when I'm not supposed to have any "credible" health insurance for 6 months.