Medicare Will Not Pay/support The Sleeve

[sdb1147 54]

Hi all. Just to update my progress, I spent the better part of 5-hours at Swedish Hospital yesterday (Seattle, WA) going through various introductions to team member, procedures, an EKG, psychiatric evaluation, photos & body measurements, nutritionists & meeting with the doctor (Dr. McMahon). I was impressed with the level of sincerity & knowledge of everyone present.

My first question to the doctor was about Medicare supporting/paying for vertical sleeve surgery and he told me that Medicare does not support it. I even asked if I could participate in a study group (if one was available) and again he said the hospital had no such group & Medicare would not support it. He went on to say that it may be a long time coming before Medicare does pay for VSG, but as of today, they won't.

So, my choices for WLS are whittled down to two options: Lap-Band & Roux-en-Y. After looking over all my medical records, he recommended the RNY procedure for me. I said I had my heart set on VSG surgery, but that I would consider the Lap-Band (Plan: , mostly because it appeared to be the simplest & less invasive. He stated that the RNY procedure is the "Gold Standard" of weight loss surgery & would be the best for me due to my Type-II diabetes & other health problems (sleep apnea, high blood pressure, etc.).

Then I met with one of the head nurses & she quite emphatic about the fact that unless my blood sugar levels were not at 150 or lower for a 2-week period (documented) prior to WLS, the doctor would not operate. My blood test prior to going to the hospital was 176, so needless to say, I'm bummed!

Still have to go back for additional lab tests and an endoscopy to be performed by Dr. McMahon (June 7).

[Jeni Martin 26]

My fiancee is on Medicare and wants to have VSG. He just started his 6 month diet with his doctor. The surgeron he saw is hopeful that Medicare will start covering the VSG within the next year. He said he has written letters and gotten other doctors to write letters requesting that they cover it. However fiancee will be going to RNY if the VSG still isn't covered by that time.

[Joni 94]

Wow how disappointing for you. I'm so sorry I know the RNY is major, but the lap band has had sooo many failures and problems, and so many people regret it. I was going to go that route at first but after research decided against it. Good luck in whatever you decide to do.

[Wheetsin 714]

So, my choices for WLS are whittled down to two options: Lap-Band & Roux-en-Y. After looking over all my medical records, he recommended the RNY procedure for me. I said I had my heart set on VSG surgery, but that I would consider the Lap-Band (Plan: , mostly because it appeared to be the simplest & less invasive. He stated that the RNY procedure is the "Gold Standard" of weight loss surgery & would be the best for me due to my Type-II diabetes & other health problems (sleep apnea, high blood pressure, etc.).

This is tough. I had a lapband for 6 years. I think it's a great tool IF you look at it as a short term fix - say like a gastric balloon, only with more invasive (but quick & easy) installation.

At the same time, I'd have to be on death's door before I would consider RNY, or have it be the only option left. I'd easily have done DS over it, though DS is far from my first choice.

I assume self pay for the procedure you want (even out of country) is not an option? Perhaps with financing?

While I think Medicare is right not to cover the sleeve (not trying to be controversial, that's just MHO), I also understand that it can be frustrating not to get the coverage you want. I'd ask about a private plan that would cover it, but really - self paying the procedure would be the cheaper option.

Are you currently pursuing your pre-op requirements in hopes that it will be covered? Or are you just getting the generic stuff out of the way, so that when the time comes you can have a(ny) procedure?

[Pookeyism 1,143]

I would discourage the lap band, especially if you would have to jump through Medicare hoops to have it removed if you had problems.

[sdb1147 54]

This is tough. I had a lapband for 6 years. I think it's a great tool IF you look at it as a short term fix - say like a gastric balloon, only with more invasive (but quick & easy) installation.

At the same time, I'd have to be on death's door before I would consider RNY, or have it be the only option left. I'd easily have done DS over it, though DS is far from my first choice.

I assume self pay for the procedure you want (even out of country) is not an option? Perhaps with financing?

Thank you for the feedback. I'm retired & unfortunately my finances are limited so I can ill-afford to self-pay for $30-40,000 surgery out of pocket.

The whole point of seeking WLS is to help with my diabetes, hypertention, high blood pressure, sleep apnea, etc. When I inquired about which would help me the most, the doctor said, without a doubt, the RNY procedure.

So, that's where I'm at. Just gotta work on getting my blood sugars down a wee bit more & all things look like a "GO".

While I think Medicare is right not to cover the sleeve (not trying to be controversial, that's just MHO), I also understand that it can be frustrating not to get the coverage you want. I'd ask about a private plan that would cover it, but really - self paying the procedure would be the cheaper option.

Are you currently pursuing your pre-op requirements in hopes that it will be covered? Or are you just getting the generic stuff out of the way, so that when the time comes you can have a(ny) procedure?

[sdb1147 54]

I would discourage the lap band, especially if you would have to jump through Medicare hoops to have it removed if you had problems.

Thanks @Pookeyism so much for your feedback & suggestions. Going into this, I was really (only) looking at VSG, but without financial support from Medicare, I cannot afford any weight loss surgery out-of-pocket (retired).

I didn't think about what happens if the Lap-Band fails and have to have it removed. Good point!

[Wheetsin 714]

Thank you for the feedback. I'm retired & unfortunately my finances are limited so I can ill-afford to self-pay for $30-40,000 surgery out of pocket.

The whole point of seeking WLS is to help with my diabetes, hypertention, high blood pressure, sleep apnea, etc. When I inquired about which would help me the most, the doctor said, without a doubt, the RNY procedure.

So, that's where I'm at. Just gotta work on getting my blood sugars down a wee bit more & all things look like a "GO".

Honestly if I were where you are at health-wise, and was limited to RNY or lap, I'd go RNY as your surgeon has already suggested. Since it can't really be seen as a permanent solution, AGB is not a good way of combating the severe and persistent health issues you're having. But it sounds like you're already steering away from it, so I won't keep going on.

Just so that you know (whether this opens any more doors or not) self-pay for VSG is rarely in the range you quoted, even domestic. Those are more like the "retail" rates that surgeons bill insurance companies (and much higher than they typically pay out). My surgeon's self-pay rate is $11,999 which covers everything during the first year (which is going to be just about anything). Those who go to MX pay in the range of $3000 - $5000, I believe. If that amount is unatainable then it's a moot point, but $5000 is only 1/8 of the cost you seem to have in mind.

[mnbsleeve 87]

I don't know if this is of any use to you ... I am posting some info below. Apparently research is showing that the VSG is the way to go for diabetes. I'm wondering if you get a hold of this research, if you could push your point with medicare and get it approved!!!!Good luck with this. I can imagine how disappointing and frustrating it must be. I'm keeping you in my thoughts!!!

(PS: I don't know if you're interested in the live procedure. I'm not watching :-) but just in case I posted everthing! )

Renowned Bariatric Surgeon to perform Live Vertical Sleeve Gastrectomy on Web

Dr. Paul Cirangle, Director of Bariatric and Metabolic Surgery for Laparoscopic Associates of San Francisco, will perform a live weight loss surgery webcast on Saturday May 19, 2012 beginning at 8:00 am PDT.

The gastric sleeve procedure will be able to be viewed world-wide in real time at

www.LapSF.com/Live-Sleeve-Gastrectomy-Surgery.

Dr. Cirangle and Laparoscopic Associates of San Francisco, are generally recognized as the pioneer of the Laparoscopic Sleeve Gastrectomy, and are credited with accruing the largest and longest series of Gastric Sleeve procedures in the world, numbering more than 2300 procedures over a period of 11 years.

Weight loss surgery has recently become an important topic due to long-standing evidence that procedures such as the vertical sleeve gastrectomy are able to resolve/cure metabolic disorders such as diabetes, hypertension, and high cholesterol in a majority of overweight individuals.

Recent published reports in the New England Journal of Medicine in April 2012, clearly demonstrated the superiority of weight loss surgery, including the vertical sleeve gastrectomy, in resolving diabetes both in morbidly obese as well as modestly overweight individuals and established weight loss surgery as being vastly superior to traditional medical and dietary modalities.

The live sleeve gastrectomy procedure will be broadcast from start to finish giving non-surgical physicians as well as everyone everywhere the ability to see first hand how the gastric sleeve is performed as well as how minimally invasive surgical techniques have dramatically changed the field of weight loss surgery.

We Hope You Can Join Us for this Very Informative and Entertaining Segment!

[Almont MI sleever 17]

I am having VSG surgery next week with Dr. Garcia in Tijuana. The total price is $5000 which includes two nights in the hospital and two nights in a really nice hotel. Everything is included except your air fair to San Diego. They pick you up at the airport and provide all your transportation while there as well as taking you back to airport for your flight home. I was able to get a personal loan to pay for everything and my payments are low. Maybe this could be another option for you. I wish you the best of luck! I truly believe the sleeve is the best option out there and I hope you can find a way around this. Keep is posted!

[sdb1147 54]

I am having VSG surgery next week with Dr. Garcia in Tijuana. The total price is $5000 which includes two nights in the hospital and two nights in a really nice hotel. Everything is included except your air fair to San Diego. They pick you up at the airport and provide all your transportation while there as well as taking you back to airport for your flight home. I was able to get a personal loan to pay for everything and my payments are low. Maybe this could be another option for you. I wish you the best of luck! I truly believe the sleeve is the best option out there and I hope you can find a way around this. Keep is posted!

I'm so poor, I can't even pay attention!

Thanks for the feedback. I too believe the sleeve to be the best form of weight-loss surgery, but unless I win a lottery, the cards dealt me are RNY or Lap-Band. I was leaning towards the band, but after viewing all the horror stories on YouTube, I have a different perspective.

[Wheetsin 714]

Go to www.lapbandtalk.com and look at the complications forum...

[shangefan 193]

As a person revising from lap band to the sleeve, I wouldn't necessarily recommend the lap band. It seems as though some people have great success (and I did for 18 months) but it is slow and the long-term failure rate is pretty high. That said, I am certain you will consider all of the factors and make the right decision for you, even if it is lapband.

[MinaT 669]

If i had my choice of RNY or Lap-band I would definitely go with RNY. I only wanted the sleeve myself and though I have BCBSIL as primary and Medicare as secondary, I have done a lot of research on this subject because of the medicare.

There are places you can get the sleeve done with Medicare. First and foremost you need to make sure the bariatric program you go through is a Centers of Excellence program. I'm not talking the hospital, but the program itself. Second, you must find out if the surgeon will apply for the Randomly controlled Study.

If your doctor will write and apply to be in the study as set-forth by medicare and their program/hospital is Centers of Excellence in Bariatric it is still an attainable dream. If you get into the program, perhaps your current doctor/surgeon will give all the work-up you have had done and submit everything to a doctor than can and will do this. I thought for a while I may have to switch from sleeve to another and I would definitely chose GYN over Lap-Band because of the maintenance of fills-unfills and issues with having to have the band removed, slippage and other complications down the line. I would rather take Vitamins the rest of my life.

Here's the information

http://www.cms.gov/m...258&fromdb=true

Laparoscopic Sleeve Gastrectomy (LSG) for the treatment of obesity (BMI ≥ 35 kg/m²) is covered only in randomized controlled trials (RCTs) meeting all of the following conditions:

The study must be designed to address the following outcomes:

Prospectively, in Medicare subjects who have BMI ≥ 35 kg/m² and qualify under the patient criteria specified in Medicare’s Bariatric Surgery for the Treatment of Morbid Obesity National Coverage Determination ( NCD) (Section 100.1 Medicare National Coverage Determinations (NCD) Manual), what are the frequency and severity of the following outcomes and adverse events at 30 days, 90 days, 1 year, 2 year and 3 years or longer compared to subjects with the same patient criteria as above (see section 100.1 of the NCD manual) whose obesity treatment does not include laparoscopic sleeve gastrectomy:

• Mortality Rate
  
• Re-Operation Rate
  
• Adverse Events including stroke, myocardial infarction, leaks, infections and others
  
• Short and long term BMI
  
• Quality of Life
  
• Obesity-related comorbidities.
  

The study must adhere to the following standards of scientific integrity and relevance to the Medicare population:

• The principal purpose of the research study is to test whether a particular intervention potentially improves the participants’ health outcomes.
  
• The research study is well-supported by available scientific and medical information or it is intended to clarify or establish the health outcomes of interventions already in common clinical use.
  
• The research study does not unjustifiably duplicate existing studies.
  
• The research study design is appropriate to answer the research question being asked in the study.
  
• The research study is sponsored by an organization or individual capable of executing the proposed study successfully.
  
• The research study is in compliance with all applicable Federal regulations concerning the protection of human subjects found in the Code of Federal Regulations (CFR) at 45 CFR Part 46. If a study is regulated by the FDA, it also must be in compliance with 21 CFR Parts 50 and 56.
  
• All aspects of the research study are conducted according to the appropriate standards of scientific integrity.
  
• The research study has a written protocol that clearly addresses, or incorporates by reference, the Medicare standards.
  
• The clinical research study is not designed to exclusively test toxicity or disease pathophysiology in healthy individuals. Trials of all medical technologies measuring therapeutic outcomes as one of the objectives meet this standard only if the disease or condition being studied is life-threatening as defined in 21 CFR § 312.81(a) and the patient has no other viable treatment options.
  
• The clinical research study is registered on the www.ClinicalTrials.gov website by the principal sponsor/investigator prior to the enrollment of the first study subject.
  
• The research study protocol specifies the method and timing of public release of all pre-specified outcomes to be measured including release of outcomes if outcomes are negative or study is terminated early. The results must be made public within 24 months of the end of data collection. If a report is planned to be published in a peer-reviewed journal, then that initial release may be an abstract that meets the requirements of the International Committee of Medical Journal Editors. However, a full report of the outcomes must be made public no later than 3 years after the end of data collection.
  
• The research study protocol must explicitly discuss subpopulations affected by the treatment under investigation, particularly traditionally underrepresented groups in clinical studies, how the inclusion and exclusion criteria affect enrollment of these populations, and a plan for the retention and reporting of said populations on the trial. If the inclusion and exclusion criteria are expected to have a negative effect on the recruitment or retention of underrepresented populations, the protocol must discuss why these criteria are necessary.
  
• The research study protocol explicitly discusses how the results are or are not expected to be generalizable to the Medicare population to infer whether Medicare patients may benefit from the intervention. Separate discussions in the protocol may be necessary for populations eligible for Medicare due to age, disability or Medicaid eligibility.
  

Consistent with section 1142 of the Social Security Act, hereinafter 'The Act', the Agency for Healthcare Research and Quality (AHRQ) supports clinical research studies that CMS determines meet the above-listed standards and address the above-listed research questions.

Any clinical studies under which there is coverage of LSG for the treatment of obesity (BMI ≥ 35 kg/m2) pursuant to this NCD must be approved within two years after the publication of the final decision memorandum for this policy. We chose the two year interval based on our prior experience with the timing of Coverage with Evidence Development (CED)-supported studies. If there are no approved clinical studies on this date, this NCD will expire. Clinical studies approved by the deadline shall continue to be subject to the terms of this NCD for no longer than five years to allow for completion of the study. The NCD can be reconsidered after that date.

Recognizing that this proposal regarding the appropriate sunset interval for this coverage decision should be subject to public review and comment, CMS welcomes comments or suggestions on the appropriate sunset time for CED-supported studies for laparoscopic sleeve gastrectomy.

.