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.

Congratulations on your approval!!!  I still remember the day I got the phone call saying I was approved and that was over three years ago!  And all three of my kids had surgery in 2010 and I remember getting the call for their approval too......so exciting!

Good Luck!

Nan

Congrats on the new exciting journey you are about to embark on!

 Hello everyone! My name is Courtney && I am a stay at home "wife" if you will.. I am 24, 5'5, 308 lbs.
I have done every diet out there and can't seem to loose a frick'n pound!! I'm sure we are all battling the same thing.. I have just recently come to the conclusion to get WLS! I have no clue where to start! I don't have insurance but can get it if I can find an insurance company to "accept" me:( I am really searching for answers because noone can seem to help! If anyone can offer me any advice, I would love to hear from you:) Here is my email address, please use it! [email protected]!! Thanks for taking the time to read my story(:

Congrats on being your own advocate and a successful surgery!
I too have UHC and just attended my 1st seminar last night. I am looking to get the gastric sleeve. I was told I needed to have at least 5 yrs of tried attemps of losing weight. I cant remember all the doctors and dieticians from early age of 12! So, with your story, I am hopeful that if I show them I went to WW for a year back in 2009-2010, attempted phentamine and anything else, maybe like you, I will get approved!   ??? I hope. Thanks for your story!