Went to a bariatric seminar tonight - Medicare does not pay for the sleeve under any circumstances. BUT...(good news/my plan)

[wannabefree]

So as I stated, the Medicare does not pay for sleeve. Even if your doctor writes letters, says you need the sleeve due to other reasons, etc. I figured that since I had a prior surgery where a little bit of my small bowel (lower intestine) was removed after an accident, and because doctors have outright recommended the sleeve to me over any other surgery - that maybe I'd qualify for a necessity sleeve. Kind of like how some people qualify for a necessity breast reduction or tummy tuck. BUT I was wrong. They don't cover it under any circumstances what so ever.

BUT I am enrolled in a bariatric program at a major hospital and I am going to get all that pre-op stuff done. I'm getting my stress test and diet supplies and dunk tank bmi and EKG and sleep study and all of that done before hand. Which is what's most important to me.

I trust that the surgeons in Mexico know what they are doing. Mexico is not the favela of Brazil or a barrio in El Salvador with some gangland doctor who sews up bullet holes for a living, hacking into your stomach. As a person who is half Spanish it always kind of offended me, but at the same time I understood and even had some small concerns myself (mostly about hand washing procedures and how touchy nurses/doctors are without gloves and water quality).

So yeah. Just an update. I'm in the bariatric program and still going to self pay.

Cuz the American Governess is really dragging it's @ss when it comes to obesity treatment and prevention and reversal/care. I worked. I paid in. Now it is time for them to pay out.

[nycbiscuit]

Medicare does pay for the duodenal switch, which is the sleeve plus a re-routing of some of the small intestine. Unlike the RNY, it leaves the pyloric valve on the stomach untouched, so you don't get the dumping and other stuff that is a big drawback of the RNY.
Actually, for persons with BMI >50, and especially with those that are higher, most doctors use the sleeve as the first step in a two-step process in a DS. This is the case for me.

[wannabefree]

Medicare does pay for the duodenal switch, which is the sleeve plus a re-routing of some of the small intestine. Unlike the RNY, it leaves the pyloric valve on the stomach untouched, so you don't get the dumping and other stuff that is a big drawback of the RNY.
Actually, for persons with BMI >50, and especially with those that are higher, most doctors use the sleeve as the first step in a two-step process in a DS. This is the case for me.

I got my plastic card recently and called Meidcare and asked for all of the billing codes and used the sentence in my workbook (I actually went to a seminar at another hospital on Sept 21) and said "I am calling to see if I have a benefit for ......." and they said no.

You're saying Medicare paid for your sleeve? Or did they pay for a 2 Step DS process?

[wyyldnite]

i don't get that either. here in ohio medicare DOES pay for it. i know because the insurance guy in my hospital's program told me it would be easier for me to have gotten the surgery if i had medicare (i have ohio medicaid hmo). id ask the people in the insurance office at the hospital if they know if medicare will pay for all or part of the surgery.

[nycbiscuit]

No, I don't have Medicare.
It is my understanding that they cover RNY, LapBand, and Open and laparoscopic biliopancreatic diversions. A Duodenal Sleeve is a biliopancreatic diversions. A DS is a two-part procedure: it includes a partial gastrectomy (sleeve) and then rearranges the small intestine to separate the flow of food from the flow of bile and pancreatic juices.

With persons who have a BMI >50, it is generally thought that a sleeve alone will not resolve excess weight issues, and greater weight loss is achieved with a DS or RNY. A DS differs from the RNY in that the DS procedure keeps the pyloric valve intact. This eliminates the possibility of dumping syndrome, marginal ulcers, stoma closures and blockages, all of which can occur after other gastric bypass procedures. However, with persons who have a BMI >50, most surgeons will want to accomplish this in two steps: first the sleeve and have the patient lose a significant amount, perhaps 100-150 lbs, and then have the biliopancreatic diversion.

People who have higher BMIs (I started at 75 and weighed 470), regardless of health issues, are at significantly higher risk with any surgery. This is why even the Mexican doctors will require significant weight loss before doing the sleeve, and why most US surgeons won't perform the DS as a single procedure on very heavy patients.

Also, be advised that Medicare requires for any bariatric surgery that you have a BMI >35, at least one comorbidity, and that you participate in a six-month medically supervised weight loss program with your surgeon or PCP. Medicare also mandates that the weight loss surgery take place at a medical center designated as a Center of Excellence by the American Society for Metabolic and Bariatric Surgery or certified a Level 1 Bariatric Surgery Center by the American College of Surgeons. Check here if your hospital is a Level 1 Center or here if it is a Center of Excellence.

I understand why a sleeve is a more attractive option than a DS. And for myself in the back of my mind I'm hope the sleeve is sufficient and I don't have to go through another surgery. However, I've been morbidly obese since I was a kid, and I've done all sorts of diets and exercise programs, but chances/statistics are that a sleeve alone won't do it.

I understand you have attended a seminar and also called Medicare directly. I think you would also be wise to first discuss health and surgical concerns with a surgeon, and to discuss your particular insurance issues with the insurance coordinator at the surgeon's office. They deal with Medicare and your Part B provider on a daily basis and have a better idea than just the call center person at Medicare about the specifics for the same surgeries they deal with day in and day out and who covers what. They might be able to work with you. If you are now planning to self-pay for Mexico, plus travel expense, etc., and if Medicare doesn't pay for any portion of the procedure, they still may be able to work it out so that Medicare pays for the hospital room and board, and all the meds and the anesthesiologist and testing, etc., and the part you'd have to pay for the surgeon may be equal to or less than what you'd be paying anyway for your Mexico trip. You are probably not the first person to come through your surgeon's office who's on Medicare and has a bigger BMI. It's worth a one-on-one conversation, not only for your health, but for your particular financial and insurance issues.

Just my $0.02

[wannabefree]

I went back to the doctor's office today and spoke with the medical records, billing, and cashier lady. After about 15 minutes of back and forth, her taking phone calls, telling me the answer was no - she finally understood the "can you please just call for me it's really important" statements I kept making. I almost was able to push some tears out, and boy way I trying. But anyways, she finally showed me the book with the codes and called Medicare for me while I was there. I had to pay my $99 weight loss program first payment anyways, so she was going to have to deal with me today regardless.

43845...gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoieostomy 50 to 100 cm common channel to limit absorption biliopancreatic diversion with duodenal switch (AKA the "switch") surgery is covered. The doctor said that the stomach portion that is removed is a different shape and different size than in the "Vertical Sleeve Gastrectomy" which is code 43843, which is not covered at all, under any circumstances, for anyone, no matter what their BMI/age/comorbidities/nothing.

They are different surgeries. which is why one is covered and one is not covered. Even though one part of the surgery exists within the other - they are not the same surgery.

The sleeve is not only an attractive option, but surgically it is my only option. Even if the chances are that the sleeve won't make me lose as much weight as whatever other surgery was...due to prior surgery on my intestines, surgeries that take out more intestines is not an option FOR ME. Me personally. I am not speaking for anybody else. But solely for me. So even if I only get to 200lbs, so be it. But I can't have any other surgeries for bariatrics.

Again, nycbiscuit I am very happy that you were able to get the surgery that you needed and were able to have it covered by your insurance. However that is not the situation in my case. And I will not be having a "switch" done on the back end, because I can't. I'm not like, anti "switch", it's just not an option for me based on my personal medical and surgical history.

[wannabefree]

If you are now planning to self-pay for Mexico, plus travel expense, etc., and if Medicare doesn't pay for any portion of the procedure, they still may be able to work it out so that Medicare pays for the hospital room and board, and all the meds and the anesthesiologist and testing, etc., and the part you'd have to pay for the surgeon may be equal to or less than what you'd be paying anyway for your Mexico trip.

Well, I know my cousin got his teeth fixed when he broke one and got an infection in his root and jaw when he was overseas. And his Medicaid paid for it. So I just googled "does medicaid pay for treatment outside of the US". cuz i know they do, but i assumed it was for emergency only or a pre existing condition that flared up (cuz a friend on Medicaid had an allergic reaction to something in Brazil and Medicare reimbursed them for that).

Now THIS, is something I will definitely look into, and even if I have to buy a supplementary plan - if it is possible to get them to pay while I am in "Mexico or Canada" ... then I will.

You have opened up a whole new avenue with this one - and I sincerely thank you for it!

https://questions.medicare.gov/app/a...ited-states%3F
FAQ
Does Medicare cover me when I travel outside of the United States?


Published 07/02/2001 08:04 AM | Updated 06/10/2009 02:51 PM

Does Medicare cover me when I travel outside of the United States?

The Original Medicare Plan generally doesn’t cover health care while you are traveling outside the United States. Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands are considered part of the United States.

There are some exceptions. In rare cases, Medicare can pay for inpatient hospital services that you get in Canada or Mexico. Medicare can pay only if:

1.
You live in the U.S. near a foreign hospital, and you need emergency or non-emergency medical treatment. If a foreign hospital is closer or easier to get to from your home than the nearest U.S. hospital that can treat your condition, Medicare may pay for the services.
2.
You’re in the U.S. when you have a medical emergency. If a foreign hospital is closer or easier to get to than the nearest U.S. hospital that can treat your emergency, Medicare may pay for the services.
3.
You’re crossing through Canada without delay between Alaska and another state, and you have a medical emergency. If a Canadian hospital is closer or easier to get to than the nearest U.S. hospital that can treat your emergency, Medicare may pay for the services.

Normal or other Medicare coverage criteria also applies to the services you get in foreign settings.

Some Medicare Advantage plans may provide worldwide coverage benefits for health care needs when you travel outside the United States. You should check with your Medicare Advantage plan prior to traveling outside of the United States regarding worldwide coverage benefits.

(there is more on the page, including links to a PDF).

[wannabefree]

oops i had double posted.... and when i said medicaid, i meant medicare. sorry.

[wannabefree]

"Some Medicare Advantage plans may provide worldwide coverage benefits for health care needs when you travel outside the United States. You should check with your Medicare Advantage plan prior to traveling outside of the United States regarding worldwide coverage benefits."

Thank you, nycbiscuit.

[wyyldnite]

sorry you are having a hard time getting the surgery covered. im also sorry that the hospital is charging you for your medical weight loss program. the hospital i went to offered them for free and they also offer free post surgical support groups. guess my hospital just wants to make folks healthy and its not about the money for them.

[nycbiscuit]

Oh, I see what you're saying. I didn't even think about that route. I think the idea of foreign coverage is say if you are on vacation and need emergency medical attention and probably not so much for medical tourism (i.e. traveling abroad for elective surgery).

My initial thought though was if you are self paying for Mexico and have budgeted $XXXX, would your local facility do the surgery and would Medicare pay for room and board, etc., and you pay the surgeon's fee with the money you'd otherwise spend in Mexico?

I know in my case the surgeon's fee and the hospital bill were separate insurance claims, and considering doctors don't get anywhere near the full amount from the insurance claims, why would they make a self-pay pay the full amount?

RE: supplemental plan -- you do have Part B coverage? Because otherwise Medicare only covers about 80%.

Isn't there some exceptions or appeals process with Medicare? I would think since you are not a candidate for either the DS or RNY because of your previous intestinal surgery that there's some medical necessity for this procedure.

[wannabefree]

I'm not having a hard time getting the surgery covered - it's not covered.

And I am going to Mexico anyways.

And as I stated in my first post, no I don't qualify for the sleeve with Medicare, because the sleeve is not covered under Medicare.

I don't know...how I am not being clear. I feel like I am being pretty clear here.

If there is something that is not answered please tell me.

[Charity]

I'm not having a hard time getting the surgery covered - it's not covered.

And I am going to Mexico anyways.

And as I stated in my first post, no I don't qualify for the sleeve with Medicare, because the sleeve is not covered under Medicare.

I don't know...how I am not being clear. I feel like I am being pretty clear here.

If there is something that is not answered please tell me.

From an outsider who just read this thread - this post seems a little mean and unneccessary. nycbiscuit was jsut trying to help and show options. No need to get nasty.

[Dee Leshuz]

Huh, as another outsider, I don't see any nastiness in what you quoted. It's notoriously easy to read stuff that isn't there online. Looks like s/he was just trying to be clear, (which can also be a problem online), and was a little frustrated, but not nasty.

[nycbiscuit]

Sorry -- I'm not trying to advocate anything one way or another. IAnd although you started this thread, there are many more people who read this board and may find both your story and other people's responses helpful and informative.




So, for others out there, what Medicare covers differs from state to state. There is also a means to appeal if you feel that there is a procedure or medication that you think should be covered. Medicare Appeals

Your mileage may vary.