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Medicare coverage for revision



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I will be having my gastric sleeve converted to the RNY hopefully, in December. I was told by my provider that they never had to get the authorization up front with Medicare. She said they submitted the letter of medical necessity with the claim when they filed and they never had any problems.

I believe that Medicare has guidelines you must follow in order for them to cover my procedure. The problem is I'm not overweight, but I'm being revised due to spontaneous reflux. Everything I eat the majority of it comes back up. I definitely have the medical necessity. In my doctor's notes he states that I am malnourished and not receiving the nutrients I need to sustain life. So, basically if I don't have the procedure I'm not going to live a lot longer.

My BC/BS of AL will not cover it because I had the original procedure out of the country and didn't follow insurance guidelines that are typical for WLS. I had other insurance at the time I had the surgery. The surgery was done probably 10 years before I became effective with BC/BS of AL. I've contacted Medicare to see if they would cover and was told yes if medically necessary. Since the self pay is a lot, I want to feel warm and cozy on the idea of the surgery being covered by Medicare. Has anyone had the revision due to complications only and Medicare cover?

Thanks!

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On 9/11/2019 at 12:22 AM, WOLVESFAN1 said:

told by my provider that they never had to get the authorization up front with Medicare.

I believe that Medicare has guidelines you must follow in order for them to cover my procedure. The problem is I'm not overweight, being revised due to spontaneous reflux

@WOLVESFAN1

The providers words might be correct - but I am a firm believer in getting "official/important"

things in general in writing.

Being successful with the sleeve is great, now at a great weight.☺️

i know many ins. companies cover revisions - you might have to work harder with medicare?

and since you are no longer overweight - don't know about the coverage

Lots of OP revise from sleeve to another WLS due to reflux - hopefully your situation

will work out too

good luck bud

kathy

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Thanks Kathy! My sleeve did well for 10 years.

I've had a time with BCBS not even wanting to cover my Hiatal Hernia. I think the Hernia is what caused all my problems it was pushing 1/3 of my stomach into my chest cavity. My esophagus was damaged as well as my diaphragm. I actually had to have internal plastic surgery done on the diaphragm. My surgeon was hoping that once my esophagus settled down because it was extremely inflamed that I would get better, but it hasn't. He said it should be fine now and since I'm still having problems I had to go through all the test again and now my sleeve has developed a little pocket that my food gets stopped up in. When it gets too full I have spontaneous reflux.

I know my commercial insurance will definitely not pay, but when my Medicare goes in effect I'm going ahead with the procedure. I don't have a choice. My surgeon said I need it to sustain life. If it doesn't cover it, I will probably hire an attorney and fight them on it. Right now I don't have the energy to do anything. Hopefully, all will go well.

Thanks!

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Thanks Kathy! My sleeve did well for 10 years.
I've had a time with BCBS not even wanting to cover my Hiatal Hernia. I think the Hernia is what caused all my problems it was pushing 1/3 of my stomach into my chest cavity. My esophagus was damaged as well as my diaphragm. I actually had to have internal plastic surgery done on the diaphragm. My surgeon was hoping that once my esophagus settled down because it was extremely inflamed that I would get better, but it hasn't. He said it should be fine now and since I'm still having problems I had to go through all the test again and now my sleeve has developed a little pocket that my food gets stopped up in. When it gets too full I have spontaneous reflux.
I know my commercial insurance will definitely not pay, but when my Medicare goes in effect I'm going ahead with the procedure. I don't have a choice. My surgeon said I need it to sustain life. If it doesn't cover it, I will probably hire an attorney and fight them on it. Right now I don't have the energy to do anything. Hopefully, all will go well.

Thanks!

Okay, this is going to sound silly! Have you gone back to a nutritionalist? Do you chew your food and eat slowly? I am just asking because I have the same type of issues!

I have to undergo a new EDG. Meanwhile, I am changing my habits like eating, chewing and small bites; When I do it helps! When I don't it hurts. [emoji30]

Sent from my SAMSUNG-SM-G935A using BariatricPal mobile app

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Yes, I have seen the nutritionist. I do chew and eat slowly. I can soft scramble an egg and eat at 8AM and late after noon some of the egg still comes up. I also have problems with liquids at time. I try not to drink a lot before eating and wait a while after eating. I've stopped drinking the Protein Shakes because they apparently sit in the little pocket and sour. I know that when I have the surgery I will go through different stages of food and I know they want me to have the Protein shakes. That's why I stopped trying to get them down. I'm afraid I'm going to turn myself against them and won't be able to stomach them when I need them to heal from the surgery.

I live in a very small city. My GI doctor said there wasn't a surgeon in our area that he would feel comfortable sending me to because I am a high risk patient. I have other medical issues. He referred me to a larger hospital that's a teaching hospital and they agreed I needed to be converted, but none were willing to do the surgery. The larger hospital is over an hour away. They referred me to mayo Clinic and they are over 1000 miles away.

I have had multiple EGD's, manometry test, Barrium Swallows, Acid test, etc. Mayo repaired my hernia and diaphragm a few months back and we were hoping that would do the trick, but I continued to throw up. Mayo did the same test again and when I did the Barrium Swallows it shows the liquid spontaneously coming back up. The EGD shows the pocket that's formed in my sleeve. Basically, some food trickles down, but a lot of it backs up in the pocket and then it has no where to go, but to come back up. TMI, but I've actually had food coming back up through my nose and throat. I can't remember when I've eaten something and it not come right back up or several hours later.

We have spent thousands of dollars out of our pocket to pay for the trips to the different hospitals and for test that weren't covered by my insurance. The airline tickets and motels are several thousand dollars each time we go to the Mayo Clinic. I'm 63, but will be eligible for Medicare on 12/1/19. My current insurance will not cover the revision because I was self pay 12 years ago. I didn't have their insurance at that time, but they said that doesn't matter. They even said that if I was eligible for the revision I would still have to follow the 7 month protocol for the WLS. I can't afford to lose anymore weight and my doctor nor I can not understand why they would even say that. I could probably fight them in court, but to be honest with you I feel like I'm running out of time. My state does not offer Medicare supplements for people under 65. Therefore, I will be paying my Medicare deductibles and the 20% out of my pocket.

So, I have nerves about all of our retirement going out the window and then I'm scared to death to have the surgery, but scared not to have it.

I'm sure I've repeated a lot of what I've already written. I hope all goes well with you and you can resolve your problem without surgery. I wish I could.

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