Greg_P

Had my Medicare VSG on October 3rd. The way it works at my hospital is they do the VSG "before" they get payment approval from medicare! Odd way of doing things, director feels I have a slam dunk case for my Medicare Administrative review and will fight for me if they prove to be stubborn. Everything has gone very smoothly thus far, but I must say I'm already frustrated with another 2 full weeks of a liquid only diet. The head hunger is no joke, I've never wanted something as simple as a plain turkey sandwich in all my life! Everything looks so good, but I know it's completely off limits until the restriction is lifted.

I've completed all Medicare requirements for VSG and will go on my surgeons list for October (I'll get my firm date end of August)! My surgeon says I have a slam dunk claim, and there is no logical reason I would be denied coverage. In my Medicare Administrative Contractors region of G (MN, WI, IL), the hospitial sumbits the claim "after" the surgery is complete. My hostpital feels comfortable with their chances at a successful Medicare claim so VSG here I come! Seems backwards, and potentially risky for both the hostpital and patient but thats the way it works here. I'm crossing my fingers and hoping the decision making (MAC) approves my VSG claim without making it difficult on me and the hostpital! Check out this link for more indepth information about how making claims with Medicare for the VSG works.... http://asmbs.org/201...ve-gastrectomy/

As newme0617 pointed out, this coverage decision is so new that it has not yet made it's way into the system Medicare phone reps work out of. Don't bother calling them, instead contact your hospital's Bariatric Coordinator. Additionally, coverage for VSG will be determined "case by case" at a local level. So VSG is covered, but not for everyone at a national level like the RNY or Lapband is. I Spoke directly with my Bariatric Director this afternoon about Medicare's VSG decision. She reviewed the CMS memo decision and agreed with my interpretation that this decision was a good one and coverage appears imminent. While the "fine" details for Medicare contractors (ie hospitals) have not yet been released (billing code, guidelines for submitting, etc) she did say everything looks like a go and I will be the first patient she submits for Medicare approval next month! For those of you who have not yet had the opportunity to get a personalized nod of approval from your hospital, read this and you should feel better. This is a summarized analysis and decoding of CMS's VSG memo from The American Society for Metabolic and Bariatric Surgery (ASMBS). A true authority in all matters concerning Bariatric's. http://asmbs.org/2012/06/access-to-care-alert-the-cms-final-decision/ At long last the wait is over! If you have state (MA) Medical Assistance (Medicade) this is good news for you as well. With very few exceptions, coverage and requirements for Medicade mirror that of Medicare. I suspect that state MA will recognize the VSG no later than October when coverages for all states go through their annual update. If you have not already begun taking the necessary steps to complete the requirements to be submitted for Insurance approval, NOW is the time to get started!

Spoke directly with my Bariatric Director this afternoon about Medicare's VSG decision. She reviewed the CMS memo decision and agreed with my interpretation that this decision was a good one and coverage appears imminent. While the fine details for Medicare contractors (ie hospitals) have not yet been released, she did say everything looks like a go and I will be the first patient she submits for Medicare approval next month! For those of you who have not yet had the opportunity to get a personalized nod of approval from your hospital, read this and you should feel better. This is a summarized analysis and decoding of CMS's VSG memo from The American Society for Metabolic and Bariatric Surgery (ASMBS). A true authority in all matters concerning Bariatric's. http://asmbs.org/2012/06/access-to-care-alert-the-cms-final-decision/ At long last the wait is over! If you have state Medical Assistance (Medicade) this is good news for you as well. With very few exceptions, coverage and requirements for Medicade mirror that of Medicare. I suspect that state MA will recognize the VSG no later than October when coverages for all states go through their annual update. If you have not already begun taking the necessary steps to complete the requirements to be submitted for Insurance approval, NOW is the time to get started!

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. The beneficiary has a body-mass index (BMI) ≥ 35 kg/m2, The beneficiary has at least one co-morbidity related to obesity, and The beneficiary has been previously unsuccessful with medical treatment for obesity.

This "purposal" of CMS is not a binding decision until 6/27/2012. They could technically change their mind between now and then though I think that to be unlikley as the main reason in denying VSG coverage is lack of "long term" data. They admit the surgery is promsing which is why they purpose the clinical study but none of this is "official" until the end of June. I contacted my hostipital's Bariatric director with all this info and "hope" they are willing to answer me about participating in a clinical study by "assuming" the Memo reflects CMS's final decision. A answer would at least offer some resolve, but my hostipital may very well refuse to "extrapolate" on a Memo and tell me to ask them again when a "offical" binding decision has been made. So for right now the most you can do is see if your hostpital meets the requirements for the clinical study (Memo details this) and if they do, ask if they are willing to participate and submit qualified canidates.

The memo with CMS's recommendations for coverage of the VSG has been issued! https://www.cms.gov/...true&NCAId=258 Unfortunatley, and to my great dissapointment CMS has purposed NOT covering the VSG at this time. However, they say they will cover it (ie pay) under a clinical study provided all the required guidelines are met. Just fired off a email to my hostipitals Bariatric director to see if they meet all the requirements and are willing to participate in the clinical study for qualified patients. Im hoping they will answer under the pretence that the Memo carries over as is to the final decision and not blow me off with something like "ask us again when the final decison is given"

If you get a denial letter make sure you file a prompt appeal. Typically with most insurance compaines it's anywhere from 10-30 days window they will accept a appeal plea. Dont give up, fight them! Ask you doctor if he/she would be willing to write and sign a letter advocating their support of the VSG for you. I think you have a very soild case (if presented correctly) to win on a appeal.

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