Medicare Coverage For Gastric Sleeve Surgery?

[smitty72766 0]

Having worked in the Medicare Field and currently being on an Advantage Plan I can tell you thgat Advantage Plans MUST cover everything that Medicare covers. They are then allowed to add whatever coverages they want. So just because medicare doesn't cover something doesn't mean an Advantage Plan won't/can't.

[monty 18]

Having worked in the Medicare Field and currently being on an Advantage Plan I can tell you thgat Advantage Plans MUST cover everything that Medicare covers. They are then allowed to add whatever coverages they want. So just because medicare doesn't cover something doesn't mean an Advantage Plan won't/can't.

I will turn 68 tomorrow and was sleeved 3 weeks ago. What percentage of people over 65 do you think Medicare or advantage plans would have to cover? There is hardly anyone in the "60's" forum on this site. So sad...

[BettyBoop 28]

I will turn 68 tomorrow and was sleeved 3 weeks ago. What percentage of people over 65 do you think Medicare or advantage plans would have to cover? There is hardly anyone in the "60's" forum on this site. So sad...

OK, I have Medicare through Kaiser's Senior Advantage plan. But I am not a senior yet. Well, I'm not retirement age. I am disabled and I collect my SS. Anyway, it depends on what Senior Advantage Plan someone gets into. With kaiser, I don't have to pay 20%. I pay $125 a day for the hospital. That is it. Unless I have complications and have to stay longer. But it is $125 a day up to a certain point, then Kaiser pays 100%.

So, I am planning my surgery to cost anywhere between $125-$375, if I stay in the hospital 3 days which seems to be about the norm.

BTW, In my Kaiser support group there is a man there that just got the RouNY done. He's 72 years young. And I don't know their ages, but a hand full of seniors there...

[DrPleatman 3]

Here's your chance to petition Medicare to cover the sleeve gastrectomy. Following is text from a letter I just received from ASMBS:

Mark Pleatman MD

Dear ASMBS Member,

As you are aware, the Centers for Medicare & Medicaid Services (CMS) has opened a public discussion and comment period regarding a National Coverage Determination (NCD) for the Vertical Sleeve Gastrectomy.

Comments are open UNTIL October 30, 2011 so please access the CMS NCD comment page TODAY and support Medicare coverage for sleeve gastrectomy. To assist you in this effort, below we have provided a direct link to CMS and sample language that you can personalize in submitting your comments.

Please be sure to focus on the scientific attributes of sleeve gastrectomy and the fact that many private health plans now routinely provide coverage for this procedure. Please avoid any inflammatory language and be aware that our time is now to get CMS coverage for the vertical sleeve gastrectomy. We appreciate your support.

Sincerely,

Robin Blackstone, MD, FASMBS

ASMBS President

Jaime Ponce, MD, FASMBS

ASMBS President Elect

Ninh Ngyuen, MD, FASMBS

ASMBS Secretary Treasurer

John Morton, MD, FASMBS

Chair, ASMBS Access to Care Committee

LINK TO CMS COMMENT PAGE:

https://www.cms.gov/medicare-coverage-database/details/submit-public-comment.asp

TEMPLATE FOR COMMENTS REGARDING MEDICARE NATIONAL COVERAGE DETERMINATION FOR VERTICAL SLEEVE GASTRECTOMY

Dear Dr. Berwick,

Thank you for opening a National Coverage Determination for the Vertical Sleeve gastrectomy. As a practicing healthcare professional who treats those affected by morbid obesity, I can attest to the safety and efficacy of this procedure. Data exist to demonstrate that weight loss and complications for the vertical sleeve gastrectomy are comparable and fall between two CMS-approved weight loss surgeries --Roux-en-Y gastric bypass and adjustable gastric banding (NEJM 2009 Wolfe, JAMA 2010 Birkmeyer, Annals of Surgery 2011 Hutter).

Furthermore, Medicare coverage of vertical sleeve gastrectomy will afford those Medicare patients affected by obesity an additional treatment option for addressing their weight and obesity-related comorbidities while maintaining gastrointestinal continuity. In fact, there are circumstances where the vertical sleeve gastrectomy was an ideal treatment option for my patient:

CITE EXAMPLE

Expanding Medicare coverage for vertical sleeve gastrectomy will ensure that Medicare patients have access to the same treatment options that other non-Medicare patients already have. I wholeheartedly urge you to provide coverage for the vertical sleeve gastrectomy.

Sincerely,

[reallyrosy 161]

Can non professional add their comments or is this open only to medical personnel?

[DrPleatman 3]

Can non professional add their comments or is this open only to medical personnel?

I think it is open to anyone, though I think if you just say, "Please cover VSG because I want it" your vote may not count for much. On the other hand, it may not hurt to try.

Mark Pleatman MD

drpleatman.com

[reallyrosy 161]

I added my comment. I said that vsg provides the most choices for leading a normal life afterwards and that private companies are sponsoring the procedure...why should senior citizens be denied access to the most desireable procedure. I also pointed out the enormous amount of positive annecdotal information available on various listervs and said there's gotta be a kernel of truth here

Basically, I told them to google it but I did thank them for considering my comments. The govt loves to be thanked...maybe that'll help.

Thanks for providing the link

[Ruthie59 0]

You better make sure that covers the surgeons charges, the hospital's operating charges, the anesthesiologist charges, and the radiologist charges.

OK, I have Medicare through Kaiser's Senior Advantage plan. But I am not a senior yet. Well, I'm not retirement age. I am disabled and I collect my SS. Anyway, it depends on what Senior Advantage Plan someone gets into. With kaiser, I don't have to pay 20%. I pay $125 a day for the hospital. That is it. Unless I have complications and have to stay longer. But it is $125 a day up to a certain point, then Kaiser pays 100%.

So, I am planning my surgery to cost anywhere between $125-$375, if I stay in the hospital 3 days which seems to be about the norm.

BTW, In my Kaiser support group there is a man there that just got the RouNY done. He's 72 years young. And I don't know their ages, but a hand full of seniors there...

[BettyBoop 28]

You better make sure that covers the surgeons charges, the hospital's operating charges, the anesthesiologist charges, and the radiologist charges.

Already have. I have a small co payment of $125. I also know of others on Medicare that have had the sleeve done through Kaiser.

I'm to be there at 9am tomorrow morning. WOOT!!

[reallyrosy 161]

Betty...

All the best to you!

[Ruthie59 0]

I hope everything goes well for you. May God Bless!

Already have. I have a small co payment of $125. I also know of others on Medicare that have had the sleeve done through Kaiser.

I'm to be there at 9am tomorrow morning. WOOT!!

[BettyBoop 28]

I hope everything goes well for you. May God Bless!

Thanks so much!! I appreciate your good thoughts. When is your surgery Ruthie?

[Ruthie59 0]

You are very welcome. I don't have a sugery scheduled. I am waiting on the Sleeve to be covered by Medicare. I sure hope they do it soon. Best of luck.

Thanks so much!! I appreciate your good thoughts. When is your surgery Ruthie?

[reallyrosy 161]

Update: somehow after howling, ranting raving pleading on my part with anthem, the hospital team got them to approve my surgery for vsg 12/5

Medicare could still approve this in december or january but there was no guarantee. And I didn't want to give up aanymore of my life than I already had...so I said ok, I will pay upfront.....and then the hosp contacted me to say that anthem approved it.

Holy cow.

[BettyBoop 28]

Update: somehow after howling, ranting raving pleading on my part with anthem, the hospital team got them to approve my surgery for vsg 12/5

Medicare could still approve this in december or january but there was no guarantee. And I didn't want to give up aanymore of my life than I already had...so I said ok, I will pay upfront.....and then the hosp contacted me to say that anthem approved it.

Holy cow.

YAY!!!! I'm so happy for you Reallyrosy!!!!

Just so you know, I was sleeved on Oct 25, 2011 and medicare paid for mine. But I am in a Medicare Senior Advantage Plan. OH, I had a $125.00 co-pay. Not bad!! Not bad at all!

Anyway, make that surgery date, just in case anything changes in the New year coming up.

Good Luck to you!!