medicare approval

[jasonlugoffman 0]

Hi,I have a Medicare Advantage plan and they use Medicare guidelines they said. My doctor sent a letter with all of my medical problems and bmi, etc. It has been a month and it is still being reviewed. I hope they approve me. But did you have to do the 6 months of diet? Does losing weight on diet hurt in any way? Thanks

Karen

well i havent been banded yet but i was told that medicare requires you to go to one class and medicare pays for the whole thing but i got medicare part a and b what type do you have?? i havent heard of the advantage plan. im sure it is the same but dont get me wrong but if you got medicare a and b you will be covered and if you got medicare a and b you only got to go to one class also the diet stuff they only require you to have tried a least one 6 month diet plain well thats what they told me i thank you will be ok but let me know if you are ok and let me know if i can help you out some more if i dont know the answer im sure some one on here does lol !!!! so what have you been through so far

[martucci 0]

Hi, thanks for answering. I was hoping to skip the 6 month diet. Years past I have done 6 months but not lately. My doctor's office, the girl that works there insists they said I have to do the 6 month with my dr. giving me a specific diet, the girl said I got a denial . Well I keep in touch with my insurance company and the gentleman I talk to there said they are still reviewing it, they did not deny you. I said well she lied again then. He said well, maybe she talked to someone who asked her if I did a 6 month program. I am really uptight on this. I need another knee surgery after having the opposite knee done, torn miniscus. I think when one has surgery the other gets all the weight on it and tears the other. I feel I would benefit if I can get it done sooner. My knees hurt . My medicare advantage is an HMO, but they said they go by medicare guidelines. So I have to sit tight and the insurance guy told me to call him next week to see if anything but he said it is a positive as they have not denied it. I think the girl at the dr.'s office is lazy and don't care. Well I will hang in there.

Karen

[jasonlugoffman 0]

Hi, thanks for answering. I was hoping to skip the 6 month diet. Years past I have done 6 months but not lately. My doctor's office, the girl that works there insists they said I have to do the 6 month with my dr. giving me a specific diet, the girl said I got a denial . Well I keep in touch with my insurance company and the gentleman I talk to there said they are still reviewing it, they did not deny you. I said well she lied again then. He said well, maybe she talked to someone who asked her if I did a 6 month program. I am really uptight on this. I need another knee surgery after having the opposite knee done, torn miniscus. I think when one has surgery the other gets all the weight on it and tears the other. I feel I would benefit if I can get it done sooner. My knees hurt . My medicare advantage is an HMO, but they said they go by medicare guidelines. So I have to sit tight and the insurance guy told me to call him next week to see if anything but he said it is a positive as they have not denied it. I think the girl at the dr.'s office is lazy and don't care. Well I will hang in there.

Karen

if you dont mine me asking were are you from? and one important thing do you got a medicare card that is red and white and it says medicare part a and medicare part b on the card??? if you do i do know you will be covered also i got a packett with a number on it you can call that number and they will send you out a packett in the mail of all the doctors in your area that do the surgery. and they will also tell you if you qualify right then when you call that number if you want it ill go look for it in my file folder and get it to you sounds like to me you are getting the run around like i did and i called that number and they gave me a list of doctors and i found weight management in columbia south carolina they are good to so far but they told me that medicare requires you to have at least tried a diet for 6 month and attend 1 class and what ever else the nurses and doctors recomend then after you do all that your doctors will bill medicare you dont have medicade also do you if so thats even better they pick up what medicare dont pay if any well get back with me and i hope every thing will work out for you

[martucci 0]

Hi, thanks for the info..I am in Florida, originally from New Jersey.

I have medicare card with A & B but don't use it as my medicare advantage plan gave me their card. Medicare pays them the money each month. I do have extra help from Medicaid too, wow, this is great if they cover fully. I will call Medicare and see if they will send me a list, thank you . Yes I feel like the women in my doctor's office just don't give a care. I am very happy with my doctor but them girls are lazy and they probably say, why don't she just diet? They don't understand. Well , I am going to see what medicare says about the list.

Thanks so much.

Karen

[jasonlugoffman 0]

Hi, thanks for the info..I am in Florida, originally from New Jersey.

I have medicare card with A & B but don't use it as my medicare advantage plan gave me their card. Medicare pays them the money each month. I do have extra help from Medicaid too, wow, this is great if they cover fully. I will call Medicare and see if they will send me a list, thank you . Yes I feel like the women in my doctor's office just don't give a care. I am very happy with my doctor but them girls are lazy and they probably say, why don't she just diet? They don't understand. Well , I am going to see what medicare says about the list.

Thanks so much.

Karen

thats fine to call medicare but the number i got will give you a list of doctors that will do the surgery and they will tell you if you qualify also with medicare and medicade they will pay for everything i dont know why your doctors office has to approve you cause as long as you are over weight in my state and have a bmi of well i dont know the bmi lol !!but i feel you will be ok let me look for that number and i will get back with you now medicare might tell you the doctors and they might not they may not know but i will give you that number give me a few i got to go to the doctors my self now but when i get back ill give you that number

[strikeuptheband 16]

It never occurred to me that my insurance might reject coverage. I have United healthcare but not sure what level of coverage. Are there some companies that do not pay for this? Any idea what it costs to pay for without insurance?

I have UHC where I work also. They will cover IF.........your employer has chosen to include WLS in the plan. I found out after I went to the seminar, went to the psych doc, and paid out of pocket for the surgeons consult that my employer has excluded WLS. They explain it like if you buy a car without air conditioning, then complain that the AC doesn't work, the company won't do anything about it. Its a crock, not fair and I am really ticked off by it.

Plan B for me was to hook up with the VA Center since I am a veteran. Was told yesterday that they would only do that surgery if my BMI was over 50. Well, geez louise, its at 37 now and I can barely walk, have high BP, high cholesterol, triglicerides, and am prediabetic. I will probably be dead before I reach a BMI of 50!

My surgeon will do it for $12,500 if you pay up front. I think there are other places that charge less but you might have to go to Mexico for that!!:wink2:

Now I am trying to come up with Plan C. I don't have a clue where to turn next. Anyone have any ideas?

[martucci 0]

ok, thanks so much! I will wait on that number.

You are really nice to help out. I appreciate it. My bmi is over 40.

Karen

[JudyAnticola 2]

What state do you live in? Just curious. Funny thing I have contacted the VA also, my husband died of a service connection so I have CHAMPVA, I am hoping that they will help, but my BMI is just at 40, but I do have other comorbid issues.

I am hoping I can upgrade the UHC plan. Otherwise it will be cash, not sure how much it is here in Buffalo.

[strikeuptheband 16]

What state do you live in? Just curious. Funny thing I have contacted the VA also, my husband died of a service connection so I have CHAMPVA, I am hoping that they will help, but my BMI is just at 40, but I do have other comorbid issues.

I am hoping I can upgrade the UHC plan. Otherwise it will be cash, not sure how much it is here in Buffalo.

Judy, I live in Missouri. Let me know if there is a way to upgrade UHC, if I can pay the difference in the premium that might be worth looking into.

What gripes me about the VA is they won't do it for Veterans, but I have read on these boards that dependents of veterans who have CHAMPVA or Tricare seem to be able to get it done. (Don't mean that dependents are any more or less important), but if they won't approve it to those of us that put our name on the line and gave active service, geez....and I can't qualify to be a dependent of anyone because 1. When I was married, I wasn't his dependent cuz I was active duty, and 2, now I'm not even married to him so I am still not his dependent! (hehe but thats ok).

Good luck, hope you get approved somehow!

[Guest Icymamma]

I have the Oregon Health Plan the Plus Plan. I have called and checked with them about the requirements. I have spoken to my PCP and he told me the same requirements.

They will cover however they are very strict, and I know that each state is different that is for sure!

BMI over 3?

Type 2 Diabetes

sleep Apnea

and there are some other things, and that was no if ands or butts with making any exceptions to there list.

So I called my second insurance comp and it was providence. They have excluded it on our company plan. That exclude and weight loss help. If your employer lets you pick a plan, then you might be covered because you are paying for those rates (high Rates) :wink2:

So that just made me even more depressed because I knew that I was for sure going to have to be a self pay. So back to searching. My PCP recommend someone that was Two Hours away from where I live, not a doc that was close. ( why because with my searching I have learned they have had complaints and out of 46 patients someone died.)

Besides that though. I schedule a consult they sent me some forms and the list or the expenses broken down.

If I did the band it was $12,000 but there was $1000 for other things, like education class, Swallow test, and Cyc evaluation.

Then there is one nite in a hotel not more than 15 min from the hospital. (this was going to be for day surgery) nites

Now if I did the Gastric Bypass it was $24,500, then $1000 for the above mentioned tests. The most expensive was the hospital stay for 2 afterwards.

Now the band was done in a surgery room near the doctors office, it is a medium sized facility for day surgery. If I went to the actual hospital it was more. It was nice to see that they had there own operating room that they use.

I have checked into traveling to other states....Is it really worth it. I say YES because if your a self pay person, it can get very spendy. Some have to refi there home to make it work. Some are lucky and have money, some have insurance.

For me, Im scheduled for May 5th, and haven't gotten all my financing yet!( they know that and are willing to change things if needed) The Doctor office doesn't offer it, they give you outside companies to speak with.

Well if anyone has good tips for me, let me know, or if there is anyone who wants to bless me let me know! :biggrin2:

[jasonlugoffman 0]

Judy, I live in Missouri. Let me know if there is a way to upgrade UHC, if I can pay the difference in the premium that might be worth looking into.

What gripes me about the VA is they won't do it for Veterans, but I have read on these boards that dependents of veterans who have CHAMPVA or Tricare seem to be able to get it done. (Don't mean that dependents are any more or less important), but if they won't approve it to those of us that put our name on the line and gave active service, geez....and I can't qualify to be a dependent of anyone because 1. When I was married, I wasn't his dependent cuz I was active duty, and 2, now I'm not even married to him so I am still not his dependent! (hehe but thats ok).

Good luck, hope you get approved somehow!

hey a couple of years ago my dad went to the va here in fort jackson and they told him that he can get a va loan to do it well he didnt want a va loan and just waited it off he went this year and the doctor told him if he didnt get the surgery he would die and he asked them again and they did it for him at no cost but he had to go were you get a va loan but they directed him in the right path were it was covered i dont know what he did but i do know the people in the office were you get a va loan at helped him out with it so you may want to try there

[jasonlugoffman 0]

ok, thanks so much! I will wait on that number.

You are really nice to help out. I appreciate it. My bmi is over 40.

Karen

hey i got that number also to make you feel better my bmi is 38.somthing and i was quilified also here is the number it is 1 800 lap band and there web sight is Home but call them and they will tell if you are covered and were to go to see a doctor and all that stuff im sure when you call you will be more at ease with your self let me know what they say and god bless you and good luck

[martucci 0]

Thank you so much, you are so sweet! I will call tomorrow. Hey, that was easy right, 1 800 lapband, ha!

Thanks again, Bless you too! Best of luck on your journey!

Karen

[Futr littl Debi 0]

Hi, thanks for the info..I am in Florida, originally from New Jersey.

I have medicare card with A & B but don't use it as my medicare advantage plan gave me their card. Medicare pays them the money each month. I do have extra help from Medicaid too, wow, this is great if they cover fully. I will call Medicare and see if they will send me a list, thank you . Yes I feel like the women in my doctor's office just don't give a care. I am very happy with my doctor but them girls are lazy and they probably say, why don't she just diet? They don't understand. Well , I am going to see what medicare says about the list.

Thanks so much.

Karen

thats fine to call medicare but the number i got will give you a list of doctors that will do the surgery and they will tell you if you qualify also with medicare and medicade they will pay for everything i dont know why your doctors office has to approve you cause as long as you are over weight in my state and have a bmi of well i dont know the bmi lol !!but i feel you will be ok let me look for that number and i will get back with you now medicare might tell you the doctors and they might not they may not know but i will give you that number give me a few i got to go to the doctors my self now but when i get back ill give you that number

Martucci - be careful about choosing the doctor. Because you have a Medicare Advantage plan, you have to use one of the doctor's that is contracted with your plan. Also, if the Medicare Advantage plan is an HMO, you will need to get a referral from your primary care physician to see the bariatric surgeon. It is true that the Medicare Advantage plan will follow the Medicare guidelines, but that just means that they will cover everything that Original Medicare covers. Call the customer service phone number on your Medicare Advantage card to find out what you need to do to get the surgery covered under your plan.

Good Luck!

[jasonlugoffman 0]

Martucci - be careful about choosing the doctor. Because you have a Medicare Advantage plan, you have to use one of the doctor's that is contracted with your plan. Also, if the Medicare Advantage plan is an HMO, you will need to get a referral from your primary care physician to see the bariatric surgeon. It is true that the Medicare Advantage plan will follow the Medicare guidelines, but that just means that they will cover everything that Original Medicare covers. Call the customer service phone number on your Medicare Advantage card to find out what you need to do to get the surgery covered under your plan.

Good Luck!

yea you are right i have regular medicare and i didnt know the diference between madicare and advantage madicare but if she called that number they will tell her every thing she needs to know and that goes for any insurence cause my wife has blue cross and blue shield and it covers it so i hope she gets what she needs best luck