Does Medicare cover a band revision + plication for a BMI of 27.5?

[marfar7 1,528]

Hey all,

I've had my band now for 3 1/2 yrs and have been very successful. Lost 104 lbs in 2 yrs and was 9 lbs from my goal of 135 last year. Then 10 mths ago, I had a minor slip. One that an unfill relieved my severe reflux, but also leaving me with less (much less) restriction. I still have 6cc in my 14 cc band. 1 more cc and it causes reflux. So my drs leaving me alone since I no longer have reflux. I've been going back and forth with:

1. I live with the less-than-optimal restriction, watch calories, diet (which I swore I'd never do after getting the lapband) and do it the old fashioned way. Leaving it alone. Living with a contraption inside of me that works about 75%.

2. Demand my dr fix it. I can either have it replaced, replaced with plication, or convert to a sleeve

My ?: Medicare paid for my surgery, as my BMI was 42 and I had hypertension. Do they cover a 2nd surgery because of a complication even tho my BMI is now 27.5. Do they go by what my original BMI was or current? Will they cover adding the plication or just go for what it originally was? Not sure that I want to start fresh again, with surgery, 4 weeks of liquids, and many trips (6 hr roundtrip) to get my adjustments until they are good.

So, does Medicare cover revision of my band only or can I add plication too?

Thanks!

Marci

[cindroo 57]

They would not for my mom, unless her bmi was above 35!

[shoni 1]

I'm confused my BMI is more than 40 but I'm having to pay for my own surgery..is it because I don't have any other health problems?

[DELETE THIS ACCOUNT! 12,703]

When I had it done, they would pay if your BMI was over 35 with at least 2 co-morbidities or over 40 with no co-morbidities.

Unfortunately, I doubt very much they'd pay for it for a BMI of 27, especially considering that's not even in the obese BMI range.

Sorry.

[marfar7 1,528]

Its not like Im asking for a new band. Im asking for a correction of the 1st one, in addition id like to add plication. Aren't complications covered?

Marci

[kll724 3,055]

They covered my revision back 1 1/2 year as ago, but we are under the "new" medicare. I am not sure what, or if, they would cover your needed procedure. My surgeon said they would not cover my appointments because I was not at 35 bmi, which they did last year. So, my answer is, check with the surgeon's insurance and medicare specialist. That's my only answer. Sorry!!Karen

[line-dancer 810]

and give them a call

[DELETE THIS ACCOUNT! 12,703]

Its not like Im asking for a new band. Im asking for a correction of the 1st one, in addition id like to add plication. Aren't complications covered?

Marci

Complications are covered but I don't think they cover plication at all. Maybe it's changed in the last couple months but they were saying it was "too investigational" to cover. They only just started covering the Sleeve very recently even. Medicare is extremely picky.

[cindroo 57]

They covered my mom's first band surgery, but she had to have a bmi over 35 with 2 comorbities. Her band slipped and they covered the removal, but nothing else, unless she met the same requirements. Over 35 bmi with 2 comorbities.

[marfar7 1,528]

Thanks everyone. Don't think I'll gain weight till I hit a 35 BMI, than you. Not sure what to do. I really don't want it removed. If I have surgery, I want it replaced. As it is, I have to travel 6 hrs roundtrip for Medicare to pay for it (we have a bariatric center right in my town but they won't cover it).

And actually, I had no problems with them paying when I started this. Within 2 weeks of submitting the paperwork, I had a surgery date. Great. Just great...

Marci