I dont know if this has been discussed here yet, but I wanted to inform you all a Medicare medical review is nearly complete pertaining to official coverage of the VSG. If all goes well, we should have a peliminary decision at the end of this month (3/30/2012)! A final binding decision will be made no later than 6/28/2012.

Offical documentation can be found here....

https://www.cms.gov/medicare-coverage-database/details/nca-tracking-sheet.aspx?NCAId=258&fromdb=true

I spoke with my Bariatric Surgeons P.A. today and discussed the Medicare coverage review of the VSG. He told me based on his attendance at the annual Bariatric Surgeons convention he was told coverage for the VSG is very likley to be approved for Medicare. He did not want to cite names, but did say his information came from very reliable sources close to the review process. He went so far as to say (without prompting) "He would be shocked if the review panel rejected covering it this year".

Im starting my 6 month required supervised diet (ie Nutritionist) consultations now to be ready for submittal come October when Medicare updates it's coverage. Those of you on Medicare and Medicade who have been holding out for VSG surgery coverage I strongly suggest contacting your Hospitial's Bariatric cordinator and starting the nessicary legwork now. Starting now, I will have everything needed for insurance approval ready to go the moment coverage goes live.

~Greg

I'm glad that some people have the vertical sleeve surgery and Medicare has paid for the procedure. But, why the double standards in as much as one person in one state gets it approved while another person elsewhere gets denied. Makes no sense.

I agree, it's not fair.

Will your surgeon try to petition Medicare on your behalf? They seem to have much more pull with them than us patients. For someone with a high BMI, they can put it in as step one in a two part procedure. In other words, the first half of a gastric bypass, which Medicare will cover. Whether or not the patient decides to go through with the second part of the surgery, after initial weight loss, is a personal decision. Many don't.

Medicare needs to get it's act together and start covering this procedure and Tricare needs to start making better decisions for their patients. I do not want to be told by my health insurance company what procedure I can have, I would rather my doctor handle that thank you. You bet I'll be putting in my opinion. We need to let our opinions be known and known ASAP!!!!

I'm really surprised that the decision hasn't been made here in NYC. They seriously need to take into consideration the needs of individual patients. For example, this would be the best choice for me because it is not as complicated as Gastric Bypass, where one can even end up with malnutrition problems. Another big plus for Gastric Sleeve is that it removes the part of the stomach that that contains the craving/hunger components.

I can't wait to know the decision and I really hope they approve.

@MariNYC, I totally agree with you. After doing extensive searching & investigating over the past several months, my conclusion was that the Vertical Sleeve was the best route to go.

The "Y" surgery changes way to many things in one's body & one is forced to consume multi-vitamins & supplements for the rest of their lives. I was under the impression the surgery was supposed to help one get off pills: metformin/glipizide for diabetes, etc.

The Lap-Band surgery introduces moveable parts into one's body that are prone to failure & or re-adjustments. I don't want to be poked in the stomach with a syringe filled with saline solution everytime an adjustment has to be made. Makes me envision the saline solutions used in breast augmentation. Yuck!

Again you're correct about the nearly total elimination of Ghrelin, the hunger hormone. Vertical Sleeve surgery removes a great portion of the stomach that produces the hormone.

So, it's Vertical Sleeve for me, otherwise I'll remain a fatty!

Hi sdb1147,

So I am going to be patient and continue getting all the paperwork done with the hope that Medicare will approve. I totally agree with you. There does not seem to be much of a better choice for me. Sleeve would be best.

haha last line of your last post made me laugh.

My initial consultation with Dr. McMahon & the rest of his medical team, will be on May 17th. The first thing I plan on asking is about the vertical sleeve procedure. If they can't/won't do it, I'll look elsewhere.

I've read elsewhere on this site where Medicare has approved the vertical sleeve, yet for some reason it's not supported here in WA. Confusing at best. Why one state, but not another?

Someone also suggested I ask about participating in a case study in order to get Medicare to approve (and pay for) the surgery as long as I'm willing to be studied for statistical records.

Wish me luck.

Yes, that's what I don't get either. WA and NY are states that you would think be among the first to approve. I know the surgery is fairly new and I have also heard about the clinical trial option. In my opinion, if the surgery is fairly new anyone getting it done can still be considered in the "trial" phase. After all, the reason why they are holding back on approval is because they want more long term effects evidence. At least that's what I've heard. Anyway, what is the big difference between having it done after Medicare's approval and as a clinical trial. Is it liabilty? Are there any differences in the type/quality of care you will receive?

I wish you good luck, please keep us posted on how things turn out. Wish me luck too! June 28th cannot arrive soon enough!

@MariNYC, no matter what, I'm wishing you the best of luck for your upcoming surgery. Think of it as as adventure! When Swedish Hospital called me, the consulting nurse asked me about prior attempts (recorded) for weight loss. I told her the only medical records I have are those documented with Group Health (previous care provider) and now with Medicare. She almost sound as though that would be sufficient. I'm somewhat confused. But, remember this, the hospitals and surgeons are in this business (weight loss surgery) to make $$$ for themselves, their staff & the hospital. All the equipment & facilities used cost money. I'm remaining positive throughout.

My surgeon is going to appeal the denial for VSG. Since I will not be able to have the lap band or RNY. Medically I have to have the VSG. So pray this will work.

Wish I had that problem (in a way), getting my surgeon to push for the gastric sleeve. Unfortunately, Medicare supposedly approves only RNY or the Lap-Band, at least here in WA. I even asked him if I could be part of a study group, to which he replied there was none here.

Originally, I was totally against RNY & leaning towards the band. But after spending countless hours watching YouTube & reading research documents (pro & con), I'm starting to lean towards RNY.

Doc practically assured me my Type-ll diabetes would either be eliminated or greatly reduced.

I am in NC. Medicare only covers RNY and Band. My surgeon believes we can appeal b/c most people can have the RNY or Band but rather have the sleeve. In my case, medically I can not have the RNY or Band. Fingers cross!

Wish I had that problem (in a way), getting my surgeon to push for the gastric sleeve. Unfortunately, Medicare supposedly approves only RNY or the Lap-Band, at least here in WA. I even asked him if I could be part of a study group, to which he replied there was none here.

Originally, I was totally against RNY & leaning towards the band. But after spending countless hours watching YouTube & reading research documents (pro & con), I'm starting to lean towards RNY.

Doc practically assured me my Type-ll diabetes would either be eliminated or greatly reduced.

I had the LapBand removed in September and after my experience I could never in full confidence recommend it to anyone again. They seem to have a lot of problems with slipping and they always leave a lot of scar tissue around the stomach making other WLS surgeries more complicated. I'm currently going through the process of getting the VSG through a military treatment facility. But if I couldn't do the VSG I would have the RNY done. Good Luck and God Bless!

Thanks gingersnap for your support. Sorry about your Lap-Band experience, but I'm sure you'll be able to get some help towards your new surgery. Don't give up! I'm not. I was really hoping for the sleeve, but doc said can't do it, unless of course I pay out-of-pocket. Can't afford that.

He spent quite a while explaining both procedures (RNY vs Lap-Band) and recommended the RNY for me. He said it's the "gold standard" of weight loss surgery. I wasn't crazy about putting a plastic object in my body, or having to undergo saline adjustment shots. I keep thinking of the horror stories of women having saline solution leak into their bodies after breast augmentation.

Although RNY manipulates &/or changes your internal organs (stomach & small intestine) I'm beginning to think that may be the way to go (for me).

My surgeon's insurance coordinator told me today is the day that NY Medicare makes a final decision on the VSG. I am hoping and praying!! I met with my PCP yesterday and we agreed that if it doesn't approve, then to go ahead and do the Lap Band and he had suggested initially. Dr. Ren is one of the top Lap Band surgeons in the country and he is very confident things would go well with that. I'll just have to wait and see what happens today. I lost 7 pounds last month and keep my weight off this month. Given that it was a rough month and I didn't really try to manage my diet too much, the fact that I didn't gain any weight surprised me. I guess it's a good thing, my metabolism is cooperating. Even just those 7 pounds have made a difference. I can move around a little more easier without getting tired so quickly.

Okay, will post later. Have a good day everyone.

If my interpertation is correct, looks like coverage will be issued on a "case per case" basis as opposed to nationally. I will be contacting my Surgeon tomorrow to discuss exactally how this will work. However, I must say this appears VERY promising!!

Final Binding Decision (Full Report)

http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?&fromdb=true&NCAId=258&

Summary Conclusion

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.