Medicare in MI

[melindakreeger 9]

How doe sthis process work with Medicare? I have my seminar in 2 weeks which is my 1st appt going towards the sleeve surgery. Other than my Primary care, she is on board, but whats the steps with getting this approved under Medicare? Normally hard or easy? Wait time?

[silverthreads 183]

Do you have Original Medicare or a Medicare Advantage plan? Big difference.

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[melindakreeger 9]

Original medicare as far as I know. Its my primary, only insurance I have. Im on disability

[silverthreads 183]

If you use your Red White & Blue Medicare card (not a health plan card like Kaiser, AARP, Humana, etc.) then you're on "Original" Medicare -- sometimes called Fee For Service Medicare. That gives you a wider choice of providers, but bigger copayments.

This means that the decision on whether a service is covered is bound by a National Coverage Determination (NCD) and potentially a Local Coverage Determination (LCD) based on the contractor that pays claims for your area. I don't have access to the LCD in your area, but the NCD can be found at this link:

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=57&ncdver=5&bc=AAAAgAAAAAAAAA%3d%3d&

Basically it says that if your BMI is over 35 and you have at least one comorbidity related to obesity then you're covered for bariatric surgery. As you might imagine there are some restrictions on which procedure -- for example VSG is covered when done as a laparoscopic procedure but not as an open procedure. It's typically done laparoscopically anyway so that makes sense. (If you read through that NCD it's a little hard to follow -- it's sort of a history of what was covered when so don't worry about things like the certified bariatric surgery center requirement -- that was a requirement years ago but it isn't any longer.)

Your surgeon's office will know more I'm sure. They deal with this all the time.

I hope that helps.

[melindakreeger 9]

Thanks, that does help. Yes its the red white and blue medicare care card. I know I have 20% copays, but its better than not having the surgery covered Ill check the link you, thanks! Also, went to my primary dr today, my scale at home is off & Im 5 pounds too light for the surgery. 5 pounds! So frustrating:( Im so close to BMI 35 & have high BP & High cholesterol for years.

[silverthreads 183]

You'll have 20% copay for outpatient services and the surgeon's fees. The hospital will be a flat fee of $1,266 if I recall correctly (might be a $20 off). Won't be too bad.

I probably shouldn't say this but if you're like most of us 5 pounds gain could happen very easily... All I had to do was walk by a donut shop and breath in! (or so it seemed)

Alternatively you can have it done in Mexico (self pay) and it won't be a whole lot more. Good luck in whatever direction you decide to go.

[Mrs.Robinson2004 7]

Original medicare as far as I know. Its my primary, only insurance I have. Im on disability

I have the same u have and am paying nothing just had to wait three months waiting on my date now my doctor had to write a letter to the insurance company but.its free

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[melindakreeger 9]

Mrs Robinson,

So did the insurance have you do the 3 month appts? I seen my primary care last week, she's on board with this surgery so if I need a letter from her (Im sure I will) she said she would write one up I have seen her on & off for 2 years for weight loss so not sure if she wrotes that in a letter, If that would be good enough or if I need to see her once a month for 3 or 6 months in a row? I called medicare, they won't tell me anything, they said my surgeons office has to call & Im not there yet, My seminar is on the 20th then Ill get my 1st appt with their doc.

[Mrs.Robinson2004 7]

Only 3 months appts

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[Mrs.Robinson2004 7]

Just a lot of test that's it's just go with it have my liquor diet paper just waiting on the doctor tell when is my date

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[Mrs.Robinson2004 7]

Just a lot of test that's it's just go with it have my liquor diet paper just waiting on the doctor tell when is my date

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Yes your doctor to need to write a letter

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[silverthreads 183]

Original medicare as far as I know. Its my primary, only insurance I have. Im on disability

I have the same u have and am paying nothing just had to wait three months waiting on my date now my doctor had to write a letter to the insurance company but.its free

Sent from my SM-N900V using the BariatricPal App

[funredneckgal 17]

Hi. I've had to go through this twice because my sleep study came back negative. I have original Medicare and the requirements are a bmi of 35 or more with at least 1 commodity. You have to have a 6 month supervised diet a whole bunch of blood tests, ekg, chest x ray, psychological evaluation, and letter of recommendation from your pcp. You also have to attend the nutrition class. I am now done with everything except 1 more diet visit in august and attend the nutrition class again next week and have another consult with the surgeon. Hoping I get this done soon. Good luck with yours.

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[melindakreeger 9]

Hello funredneckgirl,

I have my 1st eval August 13th. My pcp is writing up a letter of recommendation so Ill be bringing that with me to my eval appt. Question about the 6 month supervised diet.. My pcp documented my last appt as a weight loss appt & she has me coming back next month so Ill have 2 under my belt Before my 1st eval with Beaumont So with that being said, will those appts count as supervised visits Or will it Not count thru my pcp & it has to be 6 visits from the beaumont weight loss place??

[melindakreeger 9]

Also, do you get weighed in at all these appts? The nutrition classes, psych eval & etc? I hate being weighed, my anxiety goes up bc Im embaressed being obese:(