trying to decide

[want2livethin 0]

I have been lurking in LapBand and Sleeve Talk for awhile and today I went to a weight loss seminar. I had decided the sleeve procedure was best for me but found out that Medicare insurance will not pay for the sleeve and is now requiring a 6 month supervised diet for the other procedures. My options are self-pay here, self-pay Mex., 6 months diet and hope Medicare starts paying for sleeve, 6 months diet and have gastric bypass or lapband, or forget it.

1. If I have complications here or in Mex.Medicare would not pay and if they were bad enough (a stroke, etc) it could cost hundreds of thousands of dollars.

2. Self pay here is $20,000. Mexico would mean no one to do follow up. I could afford either one, but not hundreds of thousands of dollars if necessary.

3. Medicare could take years to decide to pay for sleeve so diet would not count.

4. If I lose more than 20lbs on 6 months diet I will have a BMI less than 40 and might not qualify for band or bypass. My health problems are not severe (joints, back pain, arthritis,high choesterol, bladder leakage), but I am a senior citizen and I am in a hurry. 40 years of off and on dieting is ENOUGH

5. I don't think band would work for me and gastric bypass scares me.

What would you do?:cool0:

[atvlexpert 1]

Hi, I'm 71 and scheduled for surgery on Feb, 17th. Medicare began to cover the sleeve on Jan, 1, 2010.

Good luck,

Marilyn

[want2livethin 0]

Hi Marilyn, The insurance person at the Obesity Surgery Center said they did not cover sleeve and told me about the 6 month diet requirerment. Do you have a Medicare Advantage plan? Do you know a number to call to find out if Medicare covers it or should I keep trying to get the answer from Humana? Did you have to do the 6 month supervised diet? Oh I hope they are wrong and you are right. That would be wonderful!!!!

[atvlexpert 1]

Hi, I started the program Aug. 27th expecting to go the Lap Band route even though I had friends that were failures. I was told on the initial visit with the physician all of the reasons why I wound not be a suitable candidate. I started the program with a 6 month surgery date. After my 2nd visit with the nurse practioner told me she would recommend me for an earlier date, even though I had not lost all of the weight they wanted me to loose.

When I saw the Dr. on dec 2nd, i let him know of my desire for the sleeve instead of the RNY, because of my age and he concured.

I don't know the billing code but i have seen it quoted on this forum as well as

obesityhelp.com and thinner times forum.

Last fall I also read in one of the Los Angeles newspapers health page that medicare no longer considered the surgery experimental.

I am using the surgery center affiliated with Torrance Memorial Hospital in Torrance, Calif and I have medicare and part B with Anthem Blue Cross. In our state Kaiser is the largest HMO and they are also doing the sleeve for their medicare senior advantage patients.

good luck, i'm on my way to my monthly support meeting.

Marilyn

[atvlexpert 1]

try medicare code 43775, that's the billing code i found on another forum,

good luck

marilyn

[cwalck 1]

I saw my new surgeon yesterday and he agreed that Medicare will NOW cover the sleeve if the pre auth is worded correctly and has the correct codes. That is the way I have decided to go and I am 60. I have no problem losing weight, I just can't keep it off. I fortunatley already exercise regularly but i want to get my diabetes under control and get rid the the sleep apnea. I was on insulin for 12 years and off for the last 1 1/2 years, so much nicer! So if I succeed with this,lif will be easier for me. Fortunately my husband doesnot care either way. Am hoping to lose 60 pounds!

[want2livethin 0]

Hi Marilyn and CWALCK:

Thank you both for the info on Medicare covering the sleeve. I have spent two days waiting to hear from my Medicare Advantage insurance about this, so I have been antsy about it. Ya'll responses are encouraging. Now if they would respond positively I will be a happy woman.

Marilyn: I also am 71 and did live on the West Coast for years before moving South in my late teens. Santa Barbara in CA, Tacoma in Washington, and Klamath Falls in Oregon. Still have family in Pacific Grove.

I hope both of you will keep me posted about your journey.

CWALCK when is your surgery and do you have to do the 6 months diet with your pcp?

Marilyn: Good luck on the 17th!

Thanks again to both of you. Sandra

[atvlexpert 1]

I just had some bad news, and I though I'd share it with you. I just left the Dr's office for my pre op and they informed me that Medicare did not approve the sleeve. When I discussed my options, on Dec. 2nd I was assured that it would be covered. According to the staff they did cover last year, that was news to me. Effective Jan 1,the requests went on hold. Even though there is a code, the dr. must give a compelling reason why the other two options would not work and according to the dr. i don't have a acceptable reason why RNY will not work. I can't have the Lap Band because of a narrow esophagus.

I still have my surgery date but I'm very bewildered. I can appeal the decision but how long that would take is anyone's guest.

So we're back to square one. Now I know why so many go to Mexico for the sleeve.

Good luck

Marilyn

[want2livethin 0]

Oh Marilyn, I am very sorry. I can imagine how disappointed you must be. You were so close to your surgery date. I hope for you and for the rest of us that they will reverse the policy again. I wonder if a letter writing campaign to Medicare would do any good. Probably not. It is the government! Mexico scares me, but gastraic bypass and not having insurance coverage in case something goes wrong is even scarier. However, I know after much thought that the sleeve is the only procedure that suits me. Therefore, I am still going to keep my initial appointment with the surgeon today and proceed with the paper work in hopes of being able to have the gastric sleeve and I may consider self pay if I can find out if Medicare would cover any drastic results.

Please keep me posted on your progress and if I find out anything I will post to you. There are going to be alot of unhappy people when they find out about Medicare.

The best to you.

Sandra

[want2livethin 0]

I just got off the phone with a Humana Medicare Advantage person. They do not cover the sleeve. It doesn't matter about "Medicare" it is what each Medicare Advantage program decides to do. She said they had been studying it for two years and she said that none of the top 5 Medicare Advantage companies cover it. They (Humana) cover all the other procedures and do not require a certain period of diet supervision, but do require a record of diet tries (for want of a better word).

If every senior interested in this procedure wrote their individual companies as well as Medicare and made enough of a fuss maybe we could get someone to do something. (She did not say this, I am just trying to be proactive).

The policy does not cover any complication resulting from the surgery. So----

[atvlexpert 1]

Good morning, I didn't get much sleep, thinking about my options and I have decided to cancel the surgery date. I;m sure the sleeve is the best option for me. Torrance Memorial requires attendance at many support meetings and every one states that it is a full time job trying to get the proper nutrients and Vitamins, after gastric bypass. I own a business and I have a husband that's not well and I also need both knee's replaced. I have to be able to take medicines for that condition without the worry.

Mexico is out but I'm going explore all of the self pay options.If i pay for the surgery then the after care would have to be covered.

Maybe this was meant to be and more thought should go into making this decision.

Good luck to you,

marilyn

[cwalck 1]

I am scheduling surgery for Easter week. April 5. I do not have Medicare Advantage. I have straight medicare and I called them and they yes, under doctors orders that this is the only surgery suitable for me. he has a CPT code for it. I am going to University of Pennsylvania which is al arge teaching hospital. Don't know if that has anything to do with it.

[cwalck 1]

I would appeal. Because of previous abdominal surgeries, the sleeve works best for me unders doctors orders. So I feel very lucky. Carol

[cwalck 1]

I don't know what medicare Advantage is. I am only 60 and have straight Medicare and they told me under doctors orders, they have to cover it. It is the best forme due to previous abdominal surgeries and scar tissue, Yeah for me. I do not have to go to any pre surgery diet programs. I just get my tests done and do it.

[cwalck 1]

Sandra, fortunately I do not have pre-requisites for diet prior to the surgery. i have been the same weight for 5 years so I don't go up and down much and I am already very active. I walk 2 miles a day 5 days a week. I have a stress test next week and my upper GI and chest x ray today and I am done. they wanted to schedule for March 1 but I am moving it to Easter week. I would talk to your doctor andhave him fight it. My doc says he has gotten everyone one of them approved. carol