Monday, April 18, 2022

What Are Medicare Requirements For Bariatric Surgery

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Bariatric Surgery Facility Certification Requirements

Bariatric Surgery Program Overview

The Centers for Medicare and Medicaid Services no longer require weight loss surgery hospitals and facility to be designated Centers of Excellence in order to be covered.

According to CMS, “the evidence is sufficient to conclude that continuing the requirement for certification for bariatric surgery facilities would not improve health outcomes for Medicare beneficiaries. Therefore, CMS has decided to remove this certification requirement.”

For more information about the change, .

If you obtain/have traditional Medicare coverage, youll need to choose a facility that meets the Centers for Medicare and Medicaid Services minimum facility standards and certification requirements for Medicare bariatric surgery. to search their directory.

If you choose/have Medicare Advantage, youll need to verify that your chosen surgical team and their hospital are in your insurance companys network. Call your insurance company directly to find out.

Regardless of which Medicare plan you have or are applying for, talk with your surgeon to find out if they accept Medicare/Medicare Advantage. They may have some especially useful tips on how to streamline the process with MedicareAdvantage insurance companies in your area.

Bariatric Surgical Management Of Morbid Obesity

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Which Bariatric Surgeries Are Covered By Medicare

Medicare coverage includes a wide range of weight-loss surgeries. These include:

  • Duodenal Switch: In this surgery, 70% of the stomach is removed instead of 85% of the stomach with gastric sleeve surgery. Duodenal Switch surgery is relatively new, which means healthcare providers are not as familiar with this procedure as they are with others.
  • Lap Band Surgery: Lap band surgery involves placing a thin, adjustable ring around the upper stomach. The gastric band creates a smaller stomach, which results in feeling fuller with a much smaller amount of food.
  • Gastric Bypass: Gastric bypass involves changing the way your stomach and small intestine digest food. This results in restricting the amount of food your stomach can hold, leading to fewer calories being ingested.
  • Sleeve Gastrectomy: During sleeve gastrectomy, around 80% of the stomach is removed. This leaves a tube-shaped stomach that is significantly smaller, restricting the amount of food you can consume as a result. Note: this procedure is only(covered on a region by region basis. Check with your bariatric surgeon to ensure Medicare will cover this surgery.
  • Lap Band Fills: Lap band fills are also covered following gastric band surgery. The doctor uses a needle to insert it into the port located on your abdominal wall with lap band fills.

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Lets Take A Closer Look At The Different Types Of Bariatric Surgery

Some of the common types of Medicare bariatric surgeries include gastric bypass, lap band surgery and gastric sleeve surgery.

Gastric bypass surgery

This common malabsorptive weight loss surgery is also known as Roux-en-Y gastric bypass . In this procedure, a small stomach pouch is created to restrict food intake. The rest of the stomach is bypassed via a Y-shaped segment of the small intestine, which reduces the amount of calories and nutrients the body absorbs.

LAP-BAND® surgery

This surgery is defined as Laparoscopic adjustable gastric banding . This common weight loss procedure involves the placement of a hollow band around the upper end of the stomach, creating a small pouch and a narrow passage into the larger remainder of the stomach. The band is inflated with saline solution, which can be increased or decreased over time to alter the size of the passage.

Gastric sleeve surgery

This weight loss surgery is also commonly known as vertical sleeve gastrectomy or sleeve gastrectomy . This procedure involves the removal of the greater curvature of the stomach and approximately 80% of the stomach volume. While pyloric sphincter and stomach functions are preserved, the remaining stomach resembles a slender curved tube.

Ways To Meet The Gastric Sleeve Surgery Requirements

How to Get Weight Loss Surgery Approved?

Medically Reviewed by:

The minimum requirements to qualify for gastric sleeve surgery include:

  • A body mass index of 40 or more, OR
  • A BMI between 30 and 39.9 with a serious obesity-related health problem like diabetes, high blood pressure, sleep apnea, high cholesterol, joint problems, and many others

However, protocols are a bit more stringent if you want insurance to pay, such as requiring a 35+ BMI and a completed medically supervised weight loss program.

Patients who qualify for gastric sleeve surgery usually:

  • Are at least 80 lbs overweight
  • Are between 18 and 75 years old
  • Have a history of failed weight loss attempts
  • Thoroughly understand that the procedure is just a tool your long-term success requires you to make significant diet and lifestyle changes

Read the sections below to learn everything you need to know about qualifying for gastric sleeve surgery.

How much weight will you lose after gastric sleeve?

Before and after weight loss success

Individual results may vary

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Medicare Options & How To Apply

SECTION SUMMARY:

  • Medicare Part A, B, C, & D Explained

Applying for coverage for a Medicare plan depends on your goals and situation. As long as you meet the eligibility criteria described above, following are your options:

Part A

As explained above, qualifying individuals are usually automatically enrolled in part A unless explicitly choosing to enroll in a Medicare Advantage plan . As long as you or your spouse paid Medicare taxes during your workinglife, Part A will usually be offered at no charge.

You also have the choice to pay for Part A as a part of a Medicare Advantage plan.

Part B

If you receive Social Security, you will be automatically enrolled in Part B.

If you do not, you can apply for both Social Security and Medicare at the same time three months before the month you turn 65. See Medicare.gov formore information.

You can also enroll in Part B via a Medicare Advantage program

Part C

If you want more robust benefits than Parts A and B offer including prescription drugs, dental, vision or hearing and the option for lower out-of-pocket costs for doctor and hospital visits, Medicare Advantage is the way to go.

Part D

To obtain Medicare Prescription Drug coverage, you are required to have Medicare Part A and/or Part B. To get prescription drug coverage through a Medicare Advantage Plan, enrollment in Part A and Part B is mandatory.

Medigap

Requirement For Psychological Evaluation

Candidates for obesity surgery who have a history of severe psychiatric disturbance or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications should undergo a comprehensive evaluation by a licensed psychologist or psychiatrist to assess the patients suitability for surgery, the absence of significant psychopathology that can limit an individuals understanding of the procedure or ability to comply with life-long follow-up .

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Working With Medicare To Cover Bariatric Surgery

Understanding the protocols around federal government gastric bypass surgery can be tough. It can also be challenging navigating the Centers for Medicare & Medicaid Services website. Thats why the caring staff at Olde Del Mar Surgical is here to help. Our team is seasoned in walking patients through all that is involved in Medicare-approved bariatric surgery.

We can guide you through the process, help you avoid any pitfalls, and double-check to make sure paperwork is properly completed. Our experienced staff will ensure a smooth process and make sure Medicare properly covers your surgery.

Medicare Part B Covers A Diabetes Prevention Program

Does Medicare cover bariatric surgery?

Medicare Part B will cover your participation in the Medicare Diabetes Prevention Program if you meet the following set of required conditions:

  • You have a BMI of 25 or higher
  • Youve never been diagnosed with diabetes or End-Stage Renal Disease
  • You havent participated in the Medicare Diabetes Prevention Program before
  • You have a hemoglobin A1c test result between 5.7 and 6.4 percent, a fasting plasma glucose of 110 to 125 mg/dL or a 2-hour plasma glucose of 140 to 199 mg/dL within 12 months before attending the first core session of the prevention program

The Diabetes Prevention Program consists of 16 sessions that take place over six months. The sessions include training, tips and strategies for weight loss and managing weight from a behavior coach.

The initial six months of training are followed by six additional months of less intensive follow-up sessions and 12 more months of ongoing maintenance sessions.

Medicare beneficiaries who meet the requirements for the program pay nothing for the service.

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Who Is Not Eligible For Bariatric Surgery

An extensive pre-surgery screening process is required in most cases, which would involve a consultation with a team of professionals, including a doctor, dietician, psychologist, and surgeon, according to Mayo Clinic.

These experts will look further into your weight history, diet attempts, eating habits, exercise, stress, and other factors. They will also evaluate your health history, such as blood clots, heart problems, kidney stones, or nutritional deficiencies. Any of these may deem a person ineligible for bariatric surgery

Other factors include your mental health conditions, or whether or not you have a history of a binge-eating disorder, substance abuse, anxiety, major depression, schizophrenia, severe bipolar disorder, or issues related to childhood sexual abuse.

Even if you are approved for bariatric surgery, it could potentially be delayed or canceled if your team of doctors finds:

  • You are not psychologically or medically ready for surgery
  • You have not made appropriate diet or exercise changes
  • You have gained weight during the evaluation

Bariatric Surgery For Type

  • patients with obesitygreater than or equal tograde II and
  • patients with type 2 diabetes mellitus+obesitygreater than or equal tograde I.
  • These researchers included 10 studies with a total of 342 patients that primarily investigated a prototype of the DJBL. In high-grade obese patients, short-term excess weight loss was observed. For the remaining patient-relevant endpoints and patient populations, evidence was either not available or ambiguous. Complications occurred in 64 to 100 % of DJBL patients compared to 0 to 27 % in the control groups. Gastro-intestinal bleeding was observed in 4 % of patients. The authors do not yet recommend the device for routine use.

    The authors also noted that “long-term data regarding bariatric surgery in lower-BMI patients is relatively limited long-term results from RCTs of lower-BMI patients are still pending. Another understudied area is the relative cost-effectiveness of bariatric/metabolic surgery compared with conventional care among less obese patients with T2DM, and RCTs powered to observe “hard” outcomes such as cardiovascular events, cancer, and death are needed among patients of any BMI level”.

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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.

    Conversion Of Sleeve Gastrectomy To Roux

    Medicare Coverage for Bariatric Weight Loss Surgeries ...

    Langer and colleagues noted that due to excellent weight loss success in the short-time follow-up, sleeve gastrectomy has gained popularity as the sole and definitive bariatric procedure. In the long-term follow-up, WL failure and intractable severe reflux can necessitate further surgical intervention. These investigators carried out a retrospective analysis of laparoscopic conversions from SG to Roux-en-Y gastric bypass to assess the efficacy for reflux relief and WL success 8 out of 73 patients underwent conversion to RYGB for severe reflux or weight regain after a median interval of 33 months following laparoscopic SG . In 1 of the patients, a banded gastric bypass was performed. In both groups, conversion to RYGB was successful, as proton pump inhibitor medication could be discontinued in all patients presenting with severe reflux, and a significant WL could be achieved in the patients with WR within a median follow-up of 33 months. Post-operative complications were observed in only 1 patient as leakage at the gastrojejunostomy was successfully treated by temporary stent placement. The authors concluded that conversion to RYGB was an effective treatment for WR or intractable reflux symptoms following SG. Therefore, SG could be performed, intended as the sole and definitive bariatric intervention, with conversion from SG to RYGB as an exit strategy for these complications.

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    1 Americas Health Rankings. . . Senior Report. Retrieved from www.americashealthrankings.org/explore/senior/measure/obesity_sr/state/ALL.

    2 CMS. Coverage Decision Memorandum for Bariatric Surgery for Treatment of Comorbidities Associated with Morbid Obesity. . Retrieved from www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=160.

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    Medicare Requirements For Bariatric Surgery Coverage

    The approval process begins after meeting the FDA standards. Medicare requirements are comparable to most major insurance provider conditions. Including a referral from your doctor stating the medical necessity for surgery. Qualifications include having a body mass index of 35 or higher with at least one relating health condition .

    The FDA also requires medical documentation or health records stating a patient battled obesity during the past five years. Before approval, you must have records that prove you tried at least one medically supervised weight loss program.

    Throughout the duration, you must fully engage and actively strive to lose weight within the program. You must also show proof you tried and failed supervised weight loss program typically provided by your doctor.

    Other Medicare requirements for bariatric surgery include blood testing and a psychological evaluation.

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    Medicare Part B Covers Obesity Screenings And Counseling

    Medicare Part B covers obesity screenings and behavioral therapy for beneficiaries with a body mass index of 30 or more.

    These weight loss programs can include:

    • An initial BMI screening
    • Dietary assessments
    • Counseling to help beneficiaries focus on diet and exercise in an effort to lose weight

    Your weight loss counseling and screenings are covered in full if received from a primary care doctor who accepts Medicare assignment.

    According to Americas Health Rankings, 28 percent of Americans over the age of 65 are considered obese in 2018.1 Two of the main contributors to senior obesity are slowing metabolism and decreased activity.

    Does Medicare Cover Gastric Sleeve Surgery

    Insurance Company requirements for Gastric Sleeve Surgery #GastricSleeve

    Medicare does cover gastric sleeve surgery when available in your service area. The level of coverage also depends on whether youre getting care as an inpatient or outpatient. Gastric sleeve surgery removes and separates about 85% of the stomach, and then the remaining gets molded into a tubular shape that cant contain much food or liquid.

    Patients lose an average of 65% of extra weight after gastric sleeve surgery, which may be why it was the fastest-growing bariatric surgery in 2019.

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    How Does Medicare Cover Bariatric Weight Loss Surgery

    How Medicare covers weight loss surgery depends on the type of surgery you get, particularly whether you’re 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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