Rejoice! Medicare & Medicade Coverage For Vsg Is Currently Under Medical Review!

[Greg_P 9]

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.

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

[Greg_P 9]

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!

[Kiwi/Nanci 9]

it has passed...June 28th 2012.....we can now have our gastric sleeve....

[lovealways 22]

Medicaid passed?

[sdb1147 54]

My surgeon's insurance coordinator told me today is the day that NY Medicare makes a final decision on the VSG. I am hoping and praying!! I met with my PCP yesterday and we agreed that if it doesn't approve, then to go ahead and do the Lap Band and he had suggested initially. Dr. Ren is one of the top Lap Band surgeons in the country and he is very confident things would go well with that. I'll just have to wait and see what happens today. I lost 7 pounds last month and keep my weight off this month. Given that it was a rough month and I didn't really try to manage my diet too much, the fact that I didn't gain any weight surprised me. I guess it's a good thing, my metabolism is cooperating. Even just those 7 pounds have made a difference. I can move around a little more easier without getting tired so quickly.

Okay, will post later. Have a good day everyone.

That's great news...for NY. Out here in Washington I hope it's approved soon too. That's the original weight loss surgery I wanted, but Medicare (as of this date) doesn't support it. I'm scheduled for surgery Aug. 14 and hopefully sleeve surgery will be approved by then. Hope, hope, hope.

Thanks for spreading the word.

[kjntwins 59]

Medicare passed it on certain criteria and on case by case. What I understand it dosen't matter what state you are in.

[Oz Ley 9]

Medicare will now cover it! There's a few hoops to jump through, but they will cover it, just looked at the site.

[Alexandra39 72]

I'm so happy!!

[sdb1147 54]

it has passed...June 28th 2012.....we can now have our gastric sleeve....

Called Swedish Hospital Weight Loss Center yesterday & spoke to Linda & she said that Dr. McMahon was aware of Medicare passing sleeve surgery however, the process is slow to move from one state to another so there's no telling how long it'll be until Seattle, WA gets the go ahead. I asked her to keep informed on the processes and if it should be approved prior to my surgery date (08-14-12), I'd like to have the sleeve surgery done vs RNY.

Thanks to all of you who posted the information. Great news.

[Alexandra39 72]

Oh, same here...when I spoke to the insurance coordinator she told me they still have to figure out how to make claim before surgery because they don't want me to be stuck with a hospital bill. Even though it will be a slower process than I would have liked, (it's gonna be rough getting to and fro the hospital if we have a bad winter) I am still glad that they approved. I meet the criteria so I should be approved (hopefully)

Yes, I also thank everyone who has posted all the information. It's comforting to know we're all in this together.

I hope you get good new VST Addict

[coltonwade 27]

I applied for mediciad today .. Does anyone know what the guildelines are for revisions for medicaid ?

[Paigers 67]

I was shocked to find out that people in other states are being denied. From the first visit to my surgeon he tried to talk to me into the sleeve. I had originally went in for RnY. He told me that I was lucky to have insurance that would cover it, as many don't.

I ended up with the sleeve and am glad I did. i feel fortunate that is was covered after hearing others' stories. Good luck to everyone who is still waiting to be approved.

Hi Cherrybomb - glad to hear you were approved! Do you happen to know what are the approval requirements for Medicaid? I live in Florida as well (Ft. Lauderdale) and I am in the process of applying for medicaid. I'm just wondering if it is as difficult as it can be with private insurances.

[Alexandra39 72]

Yeah, here in NY we are still waiting for preauthorization.

[FDclerical 318]

That's awesome!!!! Connecticut Medicare has been covering it for a while now. I'm so fortunate to have State insurance. My job offers it too but with State I pay nothing for me and my daughter! ! I pay my taxes lol !!! Congratulations and good luck to you!!!

[Ciara_Reese2 7]

Today I had my first consultation with the ReStart Bariactric clinic in Merrilville, In . I did contact my medicaide insurer and before my appointment and was told that they would cover the sleeve however today the coordinator and the medical assistant both told me that Indiana was not paying for this surgery and tried to talk me into the RNY. Now after reading these thoughtful and riveting post provided by my diligent sleevers, how can i present this info to the staff and get them to at least try to bill for it. Any suggestion? Tommorow I am going to call bariatric clinics around the state and see if any has had approvals with my insurance.

Regards,

Ciara aka Hopeful Hoosier!