What is going on with Medicare? There seem to be new requirements in Virginia. Is this nationwide or just the Medicare contractor that handles Virginia. This contractor seems to be acting like a HMO.

Hello there:

I have medicare also and live in CT. I just completed my Dr., Dietitian, and Psyche evaluations. I have to attend a seminar tomorrow evening (mandatory) and then I was told I call my Dr.s office on Thursday and then it will be submitted to Medicare.

I'm 53 years old, 5'2" and 238 lbs. I have a whole slew of comorbidities. The Dietitian told me today that she couldn't forsee any problem with Medicare approving my surgery.

I hope not. Keep me informed as to what happened to you and I'll do the same.

Priscilla

At 65, 5' 11, and 430#, my BP is controlled at 110/60 from 170/110. The new requirements specify not controllable to 140/90 with 3 meds. So that now lets me out on BP.

I do not have diabetes and my cholesterol is below 200 without meds.

Have not had a sleep apnea test and I do snore heavily but my wife says she does not detect symptoms of apnea.

Might have to depend on the joint pain which only seemed to come up with the recent addition of a diuretic for the BP along with Cozaar.

The other issue is the requirement of a doctor and dietician supervised diet along with exercise for a cumulative 6 months over a period of no more than 2 years proving that I cannot lose 10% of my weight.

Duh, I have lost that same 10% so many times that it has its own phone number.

Either there are many surgeons playing fast and loose with the medicare codes or the contractor here is acting like an HMO.

Also, the office manager for the doctors is thinking about the requirement of an additional waiver in case medicare does not pay. They have apparently had some recent denials and they say that medicare will not pre-approve.

Well, based upon all these recent developments, there is no way that I would sign an additional waiver because that would relieve the provider of exercising "best efforts" and employing their "higher professional knowledge and expertise" in dealing with medicare.

Actually, I plan to have my lawyer look at the documents already signed prior to surgery to insure that I cannot be left holding the bag.

Sorry, I forgot to state that I have done all the meetings, office visits, nutritionist, nurse, and psycologist and was with days of getting a date when the doctors group involved, was hit with some denials of payment and the new requirements, which have actually been in effect since May 17 and available to the providers since early April in newsletter form.

Hey again:

Okay so here goes. BP controllable with Diovan. Cholesterol controllable with Lipitor. Can't prove sleep apnea (been for two tests) because I never went into rem sleep long enough. Has to be 6 hours. Longest period I was able to sleep was 2-1/2 hrs. Consequently, don't have the CPAP, but I do become hypoxic when I sleep, so I need two (2) L of oxygen to sleep with. I am "pre-diabetic." I have COPD, and stress incontinence. Also am on pain pills for chronic back pain caused by the weight, Flexeril and Tramadol. Medicare part D pays approx. 1400. per month in prescriptions for me. I'm surprised they haven't sent me a letter before this telling me to go for the surgery.

How long did it take you to get a response from Medicare? My documents will probably be submitted early next week?

Thanks again, and good luck to you.

Response from Medicare? That seems to be part of the problem. They say that Medicare does not give pre-approvals and the documents on the Trailblazers (Virginia Medicare contractor) website seem to support that.

The contractor issues Local Coverage Determinations (LCD) with detailed requirements for all procedures and the provider is required to comply.

Would you ask your provider if the Medicare contractor in your state does provide pre-approvals? If so, then I may look for a doctor in another state not contracted to Trailblazers. Trailblazers apparently has VA, DC, MD, DE, TX, CO, NM, and Indian reservations.

Thanks for your help.

Medicare does give pre-approvals. In fact, the coordinator of our program said that Medicare (believe it or not) is actually very fast with their pre-authorizations. It usually takes a week. The program is in Ohio.

The out-of-pocket amount is $996. Is Trailblazers what they call a "Medicare Intermediary"? There are several of those in Ohio, like Nationwide.

I got pre-approved at the end of May and had the surgery on June 4. I had a BMI of 40.4. My supplemental insurance, Humana Traditional, has a WLS exclusion. I didn't know that because this policy is through my former employer and there are literally no written materials about what it covers nor is there any way to access that info. on the website.

Are you aware that Medicare will only cover surgery at a center designated a "Bariatric Center of Excellence"?

There are no requirements about losing a certain amount of weight beforehand or being on a physician-supervised diet.

I have surgery scheduled for Aug 8. Where is everyone seeing/hearing this about new requirements??

Serena:

Hi! Luckily my surgeon and hospital are one of the "Bariatric Centers of Excellence," here in Connecticut. So, in that sense I'm all set. I have no clue however, what a Medicare Intermediary or Trailblazer is? duh!

Never heard of it, or what they do.

I went to the required support group last evening and have finished all my appts. so I'm hoping everything will be submitted next week. Do you think an August surgery date is hoping for too much? Hope not!

Medicare does give pre-approvals. In fact, the coordinator of our program said that Medicare (believe it or not) is actually very fast with their pre-authorizations. It usually takes a week. The program is in Ohio.

The out-of-pocket amount is $996. Is Trailblazers what they call a "Medicare Intermediary"? There are several of those in Ohio, like Nationwide.

I got pre-approved at the end of May and had the surgery on June 4. I had a BMI of 40.4. My supplemental insurance, Humana Traditional, has a WLS exclusion. I didn't know that because this policy is through my former employer and there are literally no written materials about what it covers nor is there any way to access that info. on the website.

Are you aware that Medicare will only cover surgery at a center designated a "Bariatric Center of Excellence"?

There are no requirements about losing a certain amount of weight beforehand or being on a physician-supervised diet.

I have surgery scheduled for Aug 8. Where is everyone seeing/hearing this about new requirements??

Trailblazers is the Medicare contractor that handles payment requests from providers in Virginia. In an effort to streamline the procedure, they have instituted LCD or Local Coverage Determinations and are not doing pre-authorizations. My doctor and staff are beside themselves since they had some denials after the work was done.

I am aware of the hospital requirement and St. Marys in Richmond is correctly certified.

The issue on weight loss is that you have to prove that you cannot lose 10% of your body weight with a supervised program of doctor, dietician, and excercise.

Purportedly, the old requirements and maybe still for the rest of the country were 1) BMI > 35; 2) two comorbidities; 3) psyc evaluation.

Now, in Virginia, it appears the requirements are 1) BMI > 35; 2) one comorbidity; 3) psych evaluation; 4) doctor weight loss program for cumulative 6 months over a 2 year period proving that you cannot lose 10% of your body weight.

The BP comorbidity is not accepted unless three BP medicines together will not reduce BP to 140/90.

I had completed all the steps under the old program and was expecting a surgery date to be set.

I am angry because the new guidelines were available to providers as early as April 10 and were effective May 17. My provider did not avail themselves of the new requirements and allowed me to sail blissfully along on the basis that I met the requirements and Medicare would pay. This time could have been utilized with my cardiologist and PCP working to meet the new requirements in Virginia.

Now that I know Medicare does pre-approvals outside VA, DC, MD, DE, TX, CO, and NM, I may go to another state if that will work with the Medicare contractor there.

I left a message on my surgeon's APRN voice mail. She handles scheduling. She just returned my call and said with Medicare, I don't need pre-authorization. The surgeon's office is just waiting for the results of my endoscopy and liver ultrasound from another Dr.'s office, and then I go to see her - the APRN and she schedules the surgery. Couldn't sound any simpler to me. But like they say, "If it sounds too good to be true, it probably is." (Keeping my fingers crossed)

I left a message on my surgeon's APRN voice mail. She handles scheduling. She just returned my call and said with Medicare, I don't need pre-authorization. The surgeon's office is just waiting for the results of my endoscopy and liver ultrasound from another Dr.'s office, and then I go to see her - the APRN and she schedules the surgery. Couldn't sound any simpler to me. But like they say, "If it sounds too good to be true, it probably is." (Keeping my fingers crossed)

OK, the contractor there also has apparently set out Local Coverage Determinations with all the requirements.

What happens if the contractor does not agree and denies the payment like apparently happened to my provider, now going very cautious, and my surgery date is way off now, if at all, because of that and the new requirements.

It is also possible that my provider has been playing fast and loose with the codes and got caught.

I appreciate you checking on that for me.

Hey rat427:

Since you mentioned BP - I lightly touched on the subject of nearly dying in my journal, but let me tell you a little story - short version - regarding the mixing of BP medications. Last July 19th, I was rushed to the ER and nearly died. I was hypoxic - < 84 %, and had no clue what was going on, had bilateral cellulitis - which is pretty uncommon, - at least bilaterally, and I was in acute renal failure. - My nephrologist later told me he believed the kidney failure was caused 'iotragenically' (sic) meaning - by a combo of BP meds. If you are on a combo, please be diligent about making sure your PCP sends you for bloodwork often.

"Happy to be here - I'll be happier when I'm thin."

Pris

Two meds for BP. Cozaar gets me to 140/90 and the addition of a diuretic gets me to 110/60. Adjusted to half the Cozaar but the whole diuretic gets me to 120/80. The cardiologist added the diuretic.