I'm highly peeved Medicare refuses to pay for Sleeve

[Queendiva 0]

I am relatively new to this sight. I haven't been Sleeved yet but am very anxious to do so. At present the only way that will happen is if I am suddenly blessed with a rich benefactor or if I can convince Medicare to pay. Now we know the former won't happen so I am counting on my ability to somehow convince Medicare that it's in their best interest, as well as mine. Everyone is telling me that the chances of that are slim to none but it's all I have so I am doing as much research as I can to prepare me for the grievance I intend to visit upon them. Your prayers, best wishes, luck etc. are needed and very much appreciate. Now about my journey.

My journey began Feb. 2009. I did the four months of nutrition required for the Lapband, had my surgery date then the results of my upper GI came and I had an eroded esophagus and a hernia...no Lapband. My surgeon told me Medicare was supposed to start covering the Sleeve in January so I waited impatiently until Jan. Got a surgery date and a few days before it I was informed that Medicare wouldn't cover the sleeve. I decided to do the Bypass, got my date, arrived early really excited. One of my friends said I was as excited as if I was going to a party. I told her that's how I felt. It's show time so they roll me in the OR and I was talking and joking and the next thing I remember was waking up with a feeling that something had gone wrong. The nurses and attendants acted as if everything was a-ok. When I was returned to my room I found out that I had spent over four hours in the recovery before I woke up. To make things worse my sister told me that the doctor couldn't do the surgery because I had too much scar tissue around my intestines and heart. That made the already risky Bypass too dangerous. I had the pain without the gain. So the only wls I can do healthfully is the Sleeve which I think is the best surgery anyway, but we are back to Medicare not paying for it. I saw a post on another sight that made me feel that it just may be possible to get Medicare to pay for it. I am 60 years old with enough co-mobidities to kill a horse and I will get on my arthritic knees and beg if that will get Medicare to pay. With the surgery my health will be so improved plus I would love to be around a few more years to watch my six year old grandson grow up.

If anyone has any suggestions or knows someone who has gotten Medicare to pay please enlighten me.

Edited March 21, 2010 by Queendiva

[LAN2k 18]

I had straight medicare while I consulted with my surgeon and went through all the required pre-op testing. At that time Medicare would not pay for the VSG because it was considered "investigational". Before having my surgeon submit the documentation I gathered from all the tests and my medical history validating comorbidity, etc., I switched to GHI Medicare PPO III. I was not sure if they would approve the sleeve but I was sure I'd have half a chance with a medicare advantage plan. GHI Medicare approved my surgery within 2 weeks of the surgeons submission. They even had a representative phone me to tell me I was approved! I was besides myself in awe, (I really thought I'd have to appeal and my surgeon was ready to go to bat for me). My date for surgery was scheduled 2 weeks after that. It seems to me that you have sufficient reason to have documented the sleeve as medically necessary. Best wishes to you. I do hope you are able to get the approval. Do let us know how you make out.

[Tiffykins 672]

Best wishes with getting Medicare to cover the sleeve. I know several patients that have fought and fought with them. Hopefully, they will start covering it soon.

Please keep us posted on your journey, and best wishes on getting your sleeve.

[janagirl33 0]

Medicare advantage plans will pay for the sleeve depending on the contractor such as Trailblazers or National Gov. The jerks Noridian and Palmetto GBA will not pay. These darn intermediary companies (middle man) for medicare makes their own medicare guidelines per the state they represent.. It is such a Joke.. GHI medicare is not in my state so I am "f&*()kd.... scheduled for RNY but just don't know if this is the one for me. Much more invasive laparoscopic surgery.. Oh Well.. Im sick and I need to get healthy but not sicker by choosing the wrong WLS.... Tell me if you know anything different

[LAN2k 18]

What about Aetna? I am wondering if you have that advantage plan in your state? I think they may approve if "medically necessary"...but if available you will need to check. I'm sorry that you are in this predicament. I know because I too was thinking of having the RNY if I couldn't get approved for the sleeve. I hope you find a way to get what you want.

[Queendiva 0]

I have checked and we don't have GHI, but I do get statments from Trailblazer although I am using regular Medicare. If I could find provider that would OK the Sleeve I would change. I guess I will call Medicare to find out.

[Jenslim4good 1]

These are the reasons I chose the mini vacation plan and a VISA. I know it would add to the many "dumb decisions" my family would say I have made since my husband was killed in a car accident 12 years ago, but it feels right for me. What is another debt, when I have too much "stupid" debt anyway. I have Humana Gold Choice and all they have done is raise my premiums and lowered my Rx coverage! Good luck to you, my best.............and prayers. Jen in Missouri

[notsofluffy 3]

What is really irritating is that MediCAID will cover WLS.