WLS and Medicare approval

[over65 133]

I am at the very beginning of approval process. Attended orientation and waiting for initial appointment in January. I am age 66 and have Medicare & Supplement Policy. BMI=45, 245 lbs. 5'1" tall. Have a number of obesity-related comorbidities which my primary reason for looking at bariatric surgery.

Most health insurance companies require 3-6 month medically supervised weight loss program showing some successful weight loss on own for approval. Medicare is totally weird. They require 3 months medically supervised weight loss program with full participation and you must demonstrate FAILURE to qualify. If you can lose 10% of your weight in 3 months, you won't qualify. For me, that is less than 24 pounds in about 90 days to be FAILURE. Pretty ridiculous to not qualify because first 10 pounds will only be Water loss. I don't have initial appointment until sometime in January (I guess docs want us to get through holiday season for first weigh without worrying about weight gain/loss).

Anyone here had WLS under Medicare?

[JRT Mom 919]

I just got a revision from a failed lap band to a RNY bypass with Medicare insurance and a supplement like you. The doctor's office assured me that I had met the criteria (BMI of 35 with co-morbidity and a three month diet). However, Medicare doesn't do a pre-approval process--you just get the surgery and the office submits the bill and you hope they are going to pay for it! I just got it three weeks ago and the office said no one had been denied as long as they met the criteria, but I'm sweating bullets here..,

[over65 133]

Yours was revision so maybe requirements are different than initial surgery. I would hate to end up with $10k bill if I have to pay if not preapproved.

So I still need Medicare required screening (3-month medically supervised diet with FAILURE to lose weight, psych eval, nutrition visits, etc.

Edited December 14, 2019 by over65

[New&Improved 1,780]

Everyone knows how to not lose weight..

[Mark.olypenn 5]

I'm on a revision path. Due to complications, I had my band (2005) removed 10 days ago. Met with surgeon in first of September to discuss revision to VSG or RNY with Medicare and Supplement. While the surgeon's staff gave me a list of requirements for Medicare, they encouraged me to research the Medicare requirements on my own. I verified the listed requirements were accurate. I called my Supplement plan, and they said they would follow whatever Medicare required. The surgeon also stated that Medicare has no pre-approval process, which seems crazy. He commented, if the hospital agreed to move forward with the revision based on satisfactory completion of the Medicare requirements it would be approved. I still would like to have a confirmation from Medicare for piece of mind, don't like surprise medical bills $$. I have lost 13 lbs. (5%), so far, in the 3 months I have been in the medically supervised weight control program. I have not heard of being denied for losing too much weight, my BMI 40.3. Good luck, it's a bit of a maze to work through.

[Duke483 40]

My surgeon's office also stated that medicare doesn't do 'pre-approvals'. But, medicare does retain the right to 'audit' the surgeries they perform. My offices requires an acknowledgement that if medicare audit shows the surgery didn't meet their requirements, then the patient may receive a bill. I was willing to pay out-of-pocket so this isn't a big deal.

And, yes, a medicare requirement is to fail the medically supervised weight loss program. I've yet to see a definition of 'failure'.