Anyone have experience with Medicare and Gastric Sleeve coverage?

20 minutes ago, RetiredDude said:

medicare and gastric sleeve coverage

@RetiredDude

about 6 years ago, medicare told me NO to the sleeve.

it was considered experimental!! A couple of years later,

NY state medicare covered the sleeve. it was "around" 2013

good luck jumping trough the hoops

kathy

Hi Retired Dude! Medicare's National coverage determination for weight loss surgery indicates they will cover open & laparoscopic Roux-en-Y gastric bypass, open & laparoscopic Biliopancreatic Diversion with Duodenal Switch, and laparoscopic adjustable gastric banding for Medicare beneficiaries who have a body-mass index ≥ 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. These procedures are only covered when performed at facilities that are: (1) certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center (program standards and requirements in effect on February 15, 2006); or (2) certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (program standards and requirements in effect on February 15, 2006).

The following bariatric surgery procedures are non-covered for all Medicare beneficiaries:

• Open adjustable gastric banding;
• Open and laparoscopic sleeve gastrectomy; and,
• Open and laparoscopic vertical banded gastroplasty.

With that said, however, individual state (local) Medicare contractors MAY cover laparoscopic vertical gastric sleeve surgery. In what state do you live? I would be happy to find policies set forth by the Medicare contractor in your state. In Pennsylvania, the local Medicare contractor is Novitas Solutions and their policy, in part, indicates:

Laparoscopic SLEEVE GASTRECTOMY for morbid obesity is covered under Local Coverage Determination by this contractor to include patients with the three above criteria (BMI 35 or greater, at least one comorbidity related to obesity and previous unsuccessful medical treatment for obesity) as the following:

• Laparoscopic SLEEVE GASTRECTOMY for a 'stand-alone' procedure (i.e., not as part of staged procedure or part of failed attempt that moves to an open procedure)

You are amazing! Thank you, thank you. I live in Ohio.

Hello again! Evidently, I used old info regarding Medicare's stance on laparoscopic vertical sleeve surgery; Medicare actually updated the National Coverage Determination to include LVSG on 6/27/12, so it would appear that all Medicare contractors will cover the laparoscopic sleeve gastrectomy.

.....as long as it is performed as a "stand-alone" procedure.

Medicare beneficiaries who have a body-mass index ≥ 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity.

How do they determine if you have been previously unsuccessful with medical treatment for obesity? Do they require a 6 month supervised weight loss program or will telling your doctor about the diets you've been on do?


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On 1/18/2018 at 2:29 PM, AK37 said:

How do they determine if you have been previously unsuccessful with medical treatment for obesity? Do they require a 6 month supervised weight loss program or will telling your doctor about the diets you've been on do?


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Not sure if Texas is different, but medicare has no requirements for supervised weight loss, 6 months or otherwise. They do cover the sleeve gastrectomy. The approval is fairly straightforward compared to some private insurances. Hope that helps some.

Thank you [emoji5]

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Retired Dude, did you get your surgery yet? I'm also in Ohio, Medicare's covering me without a flinch on their part. I'm in Central Ohio 14 miles from the Geographic Center, if you know your Ohio geography you'll know where I live. Where are you located? I've heard from somebody in Zanesville, she has been the closest to me on Bariatric Pal. At any rate best wishes to you and anybody else reading this.

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Medicare covered mine. Just had to get Dr reports saying it was needed to be healthy. No problems.

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And do you have Medicare also?