Friday, November 25, 2022

Does Medicare Pay For Weight Reduction Surgery

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Does Medicare Cover Liposuction

Insurance and Other Payment Options for Bariatric Surgery

Medicare covers liposuction thats medically necessary. The terms for weight loss surgery are extensive. An abdominoplasty, or tummy tuck, that meets certain standards will have coverage.

An example of a scenario where Medicare will cover the costs of liposuction is if you have lipedema. You need a doctor to write a statement about why liposuction is essential for treatment.

Prophylactic Mesh Placement For Prevention Of Incisional Hernia After Open Bariatric Surgery

In a systematic review and meta-analysis, Dasari and colleagues examined if mesh prevents post-operative incisional hernia in open and laparoscopic bariatric surgery patients. A total of 7 studies met inclusion criteria. These investigators abstracted data regarding post-operative IH development, surgical site infection, and seroma or wound leakage and performed a meta-analysis. The prophylactic mesh group had significantly decreased odds of developing IH than the standard closure group . No included studies evaluated outcomes after prophylactic mesh during laparoscopic bariatric surgery. The authors concluded that prophylactic mesh during open bariatric surgery appeared to be beneficial in reducing post-operative IH without significant increasing the odds of surgical site infection or seroma or wound leakage. Moreover, they stated that higher quality studies, including those in laparoscopic patients, and cost-utility analysis, are needed to support routine use of this intervention.

What Is A Gastric Sleeve Revision

Gastric sleeve revision is a type of bariatric surgery. It is often considered an option whenever the primary gastric sleeve did not satisfy the patient.

In a gastric sleeve revision, the surgeon removes a portion of the patients stomach and joins what remains of it, forming a sleeve-like shape. After the operation, the patients stomach will be easier to get filled, meaning he/she will not be able to eat as much as he/she did before.

This should result in weight loss. To add to that, the surgery will remove the portion of the patients stomach that produces a hormone that boosts his/her appetite.

This surgery is recommended for people who have a BMI of at least 40 and have tried diet and exercise but did not have any effects.

The surgery will start with the surgeon making a few incisions in your belly. The surgeon will then insert a tiny camera called a laparoscope and will take pictures and send them to the computer.

Then the surgeon will insert other medical instruments to remove approximately ¾ of your stomach. After that, the rest of your stomach will be reattached. After the surgery, you will have to stay in a hospital for 2-3 days.

Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. Always be sure to double check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.

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What Is The Wait Time For Bariatric Surgery Using Medicare

There is no set time for Medicare to approve weight loss surgery, but its a surgery that your doctor or Medicare doesnt enter into lightly.

Facilities that perform bariatric surgery have real-world experience working with Medicare and other insurances and know what it takes to get approval for weight loss surgery.

So even though Medicare states that the only pre-surgery requirements are

  • A BMI of 35 or more
  • At least one co-morbidity related to obesity
  • An unsuccessful medical treatment for obesity

For example, North Carolina Surgery tells Medicare beneficiaries, Patient will be required to be seen monthly for six consecutive months. Medicare will require you to start the program over if a monthly appointment is missed. And the University of Pittsburgh Medical Center states, without mentioning Medicare specifically, that bariatric patients must take Six bariatric presurgical lifestyle classes to fulfill insurance requirements.

So while Medicare doesnt explicitly have a waiting period for bariatric surgery, facilities that work with Medicare can provide some perspective.

What extra benefits and savings do you qualify for?

How Does Medicare Cover Bariatric Weight Loss Surgery

Does Medicare Cover Weight Loss Surgery?

How Medicare covers weight loss surgery depends on the type of surgery you get, particularly whether youre an inpatient or outpatient. So, we first need to understand the parts of Medicare.

  • Medicare Part A is also known as hospital insurance, because it covers inpatient care received in a hospital or skilled nursing facility .
  • Medicare Part B is also known as medical insurance, because it covers outpatient services like doctor visits, lab work, mental health care, and durable medical equipment .
  • Medicare Part C is more commonly known as Medicare Advantage. These are health insurance plans provided by private insurance companies working under guidelines set by the Centers for Medicare & Medicaid Services . When you join a Medicare Advantage plan, you get your Parts A and B benefits in one policy. In addition, most Advantage plans also provide extra benefits, like prescription drugs and routine vision and dental care.
  • Medicare Part D provides prescription drug coverage. As with Part C, private insurance companies sell Part D prescription drug plans. You may get these benefits through a Medicare Advantage Prescription Drug plan or by joining a standalone Medicare Part D plan.

Original Medicare includes Parts A and B. You may also join a Medicare Supplement Insurance plan, more commonly known as Medigap. These plans help pay some of your out-of-pocket costs when you have Original Medicare. You cannot have both a Medicare Advantage plan and Medigap.

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Medicare Covers Gastric Sleeve Surgery And More

The following types of bariatric surgeries may be covered by Medicare:

  • Gastric Bypass
  • Lap Band or Realize Band
  • Duodenal Switch
  • Sleeve Gastrectomy

In addition to the procedure itself, Medicare can cover lab tests, medications, durable medical equipment, hospital room and board as well as post-operative checkups.

Will A Medicare Advantage Plan Cover Weight Loss Surgery

Coverage for any procedure with a Medicare Advantage plan can change depending on a range of circumstances. UnitedHealthcare has an Advantage plan that covers weight loss surgery after meeting the plans guidelines.

Advantage plans determine the level of benefits and costs of service based on the service area, health condition, and medical necessity.

Medicare Advantage beneficiaries should contact their policy directly if unsure about coverage and benefits.

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  • How Much Is Covered


    The extent of the Medicare coverage varies depending on the plan that you are involved in. This said, most Medicare base plans cover 80 percent of the amount of the surgery that is considered to be approved by Medicare. The rest may be covered by the MediGap supplement plan and could leave you with no expenses left to pay.

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    Medicare And Weight Loss Surgery

    Medicare covers weight loss surgery in many cases, including roux en y gastric bypass, duodenal switch, and lap band surgery. Any other weight loss procedures are deemed experimental and will not be covered by Medicare. Some of these might include a gastric balloon, intestinal bypass, or liposuction.

    However, you must meet specific coverage requirement, including:

    • Body mass index of 35 or greater
    • Passed psychological evaluation
    • An illness that is directly related to obesity
    • Documented evidence of obesity for the last five consecutive years
    • Proof of medically supervised weight loss program completion or nutritional counseling
    • A physicians letter supporting or recommending weight loss surgery
    • Normal screening tests that prove that there are no other medical issues that are causing your obesity

    Medicare looks at each case uniquely. You must be able to provide the scientific facts of your obesity, in addition to the documentation that youve met the other Medicare requirements. It may take a few months to get all of these things in order and to get an answer from Medicare to see if you have been approved.

    Other Ways To Pay For Weight Loss Surgery

    If you do not have health insurance, or if your insurer will not cover weight loss surgery, talk to your doctor and your surgeon about financing plans. Check on the interest rate, and make sure you are OK with all of the terms.

    Show Sources

    Anita Courcoulas, MD, MPH, chief of minimally invasive bariatric and general surgery, University of Pittsburgh School of Medicine.

    American Society of Plastic Surgeons: “Insurance Coverage: A Patient’s Guide.”

    American Society for Metabolic and Bariatric Surgery: “Metabolic & Bariatric Surgery.”

    WebMD Medical Reference: “Preparing for Weight Loss Surgery” and “Your Options in Weight Loss Surgery: Making the Choice.”

    National Conference of State Legislatures: “Health Reform and Health Mandates for Obesity.”

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    Sclerotherapy For Dilated Gastrojejunostomy

    The textbook Townsend: Sabiston Textbook of Surgery states that, in regard to investigational bariatric procedures, “endoscopic incisionless surgery has focused on patients after Roux-en-Y gastric bypass who have inadequate weight loss or significant weight regain and who have a dilated gastrojejunostomy. It is thought that these patients lose restriction because of the dilated gastrojejunostomy and thus overeat. Surgeons have tried endoscopic injection of sclerosing agents to create scar and a smaller anastomosis, with variable effects.”

    In a 2007 article, Spaulding, Osler and Patlak studied endoscopic sclerotherapy with sodium morrhuate of a dilated gastrojejunostomy in 147 gastric bypass patients. In a retrospective review, 32 patients were identified for whom > or =12 months of postprocedure data were available. Their weight trends before and after treatment were assessed by paired t test. A total of 32 patients who were gaining weight after gastric bypass underwent sclerotherapy of their dilated gastrojejunostomy. The timing of treatment ranged from 10 to 140 months after Roux-en-Y gastric bypass. Before sclerotherapy, patients were gaining weight at a rate of .36 kg/mo. After treatment, they were losing weight at a rate of .39 kg/mo. After treatment, 56.3% of patients began to lose weight, 34.4% had their weight stabilize, and 9.4% continued to gain weight.

    Medicare Advantage Plans May Cover Gym And Wellness Program Memberships


    Many Medicare Advantage plans offer memberships to SilverSneakers and other wellness programs as part of the Medicare Advantage plan benefits. SilverSneakers and other programs can help seniors manage their weight loss by getting more active through a number of supported fitness classes.

    Some Medicare Advantage plans may also cover healthy food options and home-delivered meals.

    Medicare Advantage plans may offer these benefits in addition to all of the Medicare Part A and Part B benefits detailed above.

    Medicare Advantage plans can help with your weight loss through programs that support healthy life habits. To learn more and to compare plans that are available where you live, call speak with a licensed insurance agent today.

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    The Overstitch Suturing Device

    Bolton et al stated that weight regain secondary to VBG pouch dilation is a typical referral for bariatric surgeons. In this study these investigators compared an endoluminal pouch reduction to RYGB for revision. A retrospective review was completed for patients with a previous VBG presenting with weight regain between 2003 to 2010. A total of 30 patients were identified . Significant post procedure BMI loss was seen in each cohort to 35 ± 7 kg/m StomaphyX 43 ± 10 kg/m to 40 ± 9 kg/m, p = 0.0007). Whereas nausea and headache were the only complications observed in StomaphyX patients, the RYGB group had a 43.5 % complication rate and 1 mortality. Complications following RYGB include: incisional hernia , anastomotic leak , respiratory failure , fistula , and perforation . The median length of stay following RYGB was 6 days compared to 1.5 ± 0.5 days following StomaphyX. The authors concluded that the findings of this study suggested that while RYGB revision may achieve greater weight loss, the complication rates and severity is discouraging. StomaphyX may be a safe alternative. Moreover, they stated that further technical modifications of the device and longer follow-up may clarify the role of this approach.

    Gastrojejunostomy For The Treatment Of Gastro

    Grover and Kothari stated that patient satisfaction with primary anti-reflux surgery is high, but a small percentage of patients experience recurrent reflux and dysphagia, requiring re-operation. The major anatomic causes of failed fundoplication are slipped fundoplication, failure to identify a short esophagus, and problems with the wrap. Minimally invasive surgery has become more common for these procedures. Options for surgery include redo fundoplication with hiatal hernia repair if needed, conversion to RNY anatomy, or, as a last resort, esophagectomy. The authors asserted that conversion to RNY anatomy had a high rate of success, making this approach an important option in the properly selected patient. This review did not provide any clinical data however, it did cite the studies by Awais et al and Makris et al .

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    Does This Information Count For Medicare And Medicaid As Well

    Yes. Medicaid, like insurance, tends to only pay for medical procedures where there is a medical need. You would need to demonstrate that the excess skin holds you back, causes discomfort or pain, and otherwise inhibits your life. Some Medicaid and Medicare requirements want you to demonstrate that you have maintained your weight for at least six months or longer and want a letter from your doctor stating that the belt lipectomy is necessary for improving your quality of life.

    Conversion To Sleeve Gastrectomy For Hypoglycemia Post

    Weight-Loss Surgery: Insurance and Pre-surgery education

    The 2017 American Society of Metabolic and Bariatric Surgery position statement on “Postprandial hyperinsulinemic hypoglycemia after bariatric surgery” stated that “Conversion of RYGB to SG has also been described in a few small series/case reports for complications related to RYGB. Reversal of RYGB with the addition of primary or staged SG specifically for treatment of refractory hyperinsulinemic hypoglycemia has been described in less than 10 patients with resolution of hypoglycemia symptoms in the majority without findings of short-term weight gain. As with RYGB reversal, these are technically challenging procedures with increased risk of complications, including a greater incidence of gastroesophageal reflux related to the addition of the SG. Currently, there is insufficient evidence to recommend this as treatment for hyperinsulinemic hypoglycemia”.

    An UpToDate review on “Late complications of bariatric surgical operations” states that “Based on the theory that severe, disabling hypoglycemia after gastric bypass surgery occurs in a subset of patients with loss of gastric restriction, with resultant rapid food passage and absorption, restoration of gastric restriction can result in symptom resolution. Gastric restriction can be restored by surgical placement of a silastic ring or an adjustable gastric band around the pouch. In one series, symptoms resolved in 11 of 12 patients with this approach”.

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    Measurement Of Serum C

    Kroll and colleagues stated that early intra-abdominal infections compromise short-term outcomes in bariatric surgery. The timely detection of IAI is challenging but essential to prevent major sequelae of such complications. C-reactive protein is a reliable marker for detecting IAI after colorectal surgery. In bariatric surgery, data on CRP as a marker for IAI are limited, especially for post-operative day-1 . These researchers evaluated CRP on POD1 as a predictor for early IAI in patients after LSG and LRYGB. Patients with bariatric surgery between August 2010 and June 2017 were included. The predictive capacity of CRP for early IAI was determined using a receiver operating characteristics analysis. In 523 patients , 16 early IAI were observed. ROC analysis revealed a significant predictive capacity of POD1 CRP for early IAI, with a sensitivity and a specificity of 81.2 % and 94.3 %, respectively, at a CRP cut-off value of 70 mg/L. In patients with confirmed early IAI, 81.3 % had a CRP level of greater than or equal to70 mg/L . The negative predictive value for a CRP level of less than70 mg/L was 99.4 % overall and was 100 % and 98 % for LSG and LRYGB, respectively. The authors concluded that in patients with a CRP level of less than70 mg/L on POD1, early IAI could be excluded with high accuracy in bariatric patients thus, these researchers stated that early post-operative CRP may be used to examine the risk of early IAI in enhanced recovery programs.

    Does Medicare Have Coverage For Plastic Surgery

    Coverage for plastic surgery for treatment or repair is likely. This can include repair after an accident or for the treatment of severe burns. Some therapeutic surgeries that serve a cosmetic change may be allowable.

    Lets say Sally has breast implants that prevent breast cancer treatment. Well, Part A can help with costs in an inpatient setting. If the procedure is done in an outpatient setting, Part B covers 80% of the costs. For the lowest cost, go to a doctor that takes Medicare.

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    Biliopancreatic Diversion With Duodenal Switch

    The duodenal switch procedure starts with a sleeve gastrectomy. Then, the lower intestine is divided, leaving only a few feet of intestine connected to the digestive tract.

    This procedure usually results in the greatest weight loss, but patients will likely have frequent and loose bowel movements and gas. Patients will also need to be closely monitored for healthy vitamin, mineral, and protein levels.

    In some cases, a doctor or surgeon may recommend that you undergo the sleeve gastrectomy first, then revisit the duodenal switch in 9-12 months.

    The duodenal switch often results in 60-80 percent excess weight loss within two years.

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