Sleeve Medicare Appeal

[Cool Headed 0]

Hi I was sleeved on Dec. 15, 2010. Medicare denied my claim. Has anyone appealed Medicare and won. I need help to get Medicare to pay for the VSG surgery. I was obese, Type II Diabetes not controlled. Diabetes showed up in my left eye in May of 2010 and I got really frighten that if I did not do something soon I could go blind in a few years. I also was afraid the Diabetes would soon attack my body in different places because my A1C was 9.4.

Somethin would happen in middle of night to drive my morning reading to be 250 to 325 and the Specialist after 16 months could not get this to stop happening to me. I read about the VSG having great results getting Type II in remission so I got the surgery. My Type II Diabetes is in remission and my A1C came back 6.2 since Dec. 15th. My morning readings are 90 to 110. I have lost 51 pounds so far. I am 61 years old. Please help me if you won a appeal against Medicare.

Thanks

[snowfie9 6]

it doesn't hurt to try. If medicare is anything like social security, appealing can only help. Do it a few times if you must.

Good luck!

[Susanne 32]

Did they say why they rejected your claim?

[Cool Headed 0]

Did they say why they rejected your claim?

[Cool Headed 0]

Medicare believes VSG is still new and they need more time to evaluate the surgery. Medicare believes Gastric Bypass is the way to go since they have more data on the surgery and it has been around longer.

Please. Medicare is behind times. VSG is the only surgery a person should be having now. No malabsorptive complications, use Nsaid for pain, ulcer less likely & life expectancy is 5 times longer than Gastric Bypass procedure. Fight for justice.

Cool Headed

[Susanne 32]

Weird, I was told at my intro seminar that Medicare definitely covers it, that's why I ask. I am wondering if that is also a state matter like for BCBS

[Cool Headed 0]

I do not know, however I got an e-mail and someone in California said Medicare paid for theirs.

Medicare is a federal program and I would think if Medicare paid for one surgery they would pay regardless of where the person lives, however I found that is not the case. My surgeon said Medicare has a code and has not used it yet to pay for VSG. I want to appeal their decision because I believe VSG was right choice for me. I also have BC/BS PPO as my second insurance. Hospital told me if Medicare does not pay that your second insurance will not either. I said that is bull. I called BC/BS and they are looking into my case.

Cool Headed.

[Stacy160 201]

Last I knew, Medicare did not pay for VSG at all -- if that's changed, great!!

I'm surprised the surgeon's office didn't try to get approval beforehand...I've never heard of anyone getting the surgery and then submitting it to insurance afterward. If you have reasons why you couldn't have RNY (have to take NSAIDs, for instance, or other intestinal problems keeping you from being bypassed) then you might try an appeal based on that... people have won their appeals in the same situation with other insurances.

[Susanne 32]

I'm surprised the surgeon's office didn't try to get approval beforehand...I've never heard of anyone getting the surgery and then submitting it to insurance afterward.

Well, from what I understand from an earlier topic, Cool Headed was informed by her/his doctor that it wasn't covered.

It's still weird, since Medicare is a federal program as someone mentioned. Is this something you can go with? I mean, if they approve it for some, they should pay for you too.

BCBS of Michigan covers it, but BCBS is a regional thing.

You said you have BCBS as a secondary insurance, did you ever check with them?

[Cool Headed 0]

Yes I checked with BC/BS PPO back in June 2010 and they told me that Medicare does not cover VSG surgery but they do. I was told by BC/BS PPO that I met their requirements and they would pay even if Medicare denied it. I have to wait & see if this is true. Shady Grove Hospital did not bill BC/BS because they said if Medicare did not pay for the surgery neither would BC/BS. BC/BS told me that is not true so I called Shady Grove Hospital and told them BC/BS want my claim to cross over to them and they will decide what to do. Shady Grove filed a claim with BC/BS after I insisted they do and start doing their job correctly. I have at least 30 days until I find out what is up. The surgeon does not take any insurance except Medicare so I need to appeal Medicare decision because until Medicare agrees to pay the surgeon I am in for $9000.00. BC/BS may pay him some money for the surgery if they pay some on the hospital. Medicare needs to get with the times & recognize VSG surgery. Gastric Bypass is becoming obsolete because VSG is much better surgery and allows the patient a normal way of living. I can eat most anything now except in smaller portions. I continue to lose weight and I feel great. No Dumping.