- Will Insurance Pay For Gastric Sleeve
- What To Know About Using Insurance To Pay For Weight Loss Surgery
- What Is A Gastric Sleeve Surgery?
- Gastric Sleeve Surgery
- Cigna Requirements Help
Will Insurance Pay For Gastric Sleeve – The field of weight loss surgery has grown exponentially over the last four years. As a result, I find myself being asked more and more questions regarding post-operative surgery. Be it plastic surgery, or a revision, the sheer number of post-op patients is increasing the demand for these two types of post-op procedures.
In this article, we will only talk about revisions. And that word, revision, gives rise to several inclusive terms such as failed surgery, non-compliance, and revision for a new procedure.
Will Insurance Pay For Gastric Sleeve
Modification is defined as changing or modifying (for our purposes, this is replacing or modifying a previous bariatric surgery). There are several areas where revisions can arise. A patient may be dealing with either revision of a failed bariatric procedure or revision of a new type of procedure that is not approved or even present at the time of the original surgery.
What To Know About Using Insurance To Pay For Weight Loss Surgery
This is a simple question, but not a simple answer. As we all know, insurance companies make decisions by throwing darts at a dartboard. So it’s natural to assume that a provider will have different answers for different individuals in different states.
To begin with, a request for a revision based on a failed previous bariatric surgery is immediately going to prompt a response from most insurance providers questioning whether the prior surgery was in fact a failure, or the patient. Was not following the requirements of the first surgery. In other words, eating behind the pouch or band.
A revision from an old procedure to a new type of procedure is going to receive similar questions with the additional question of why the patient wants to switch from Roux-en-Y to gastric banding or duodenal switch.
Before making such a request, it is imperative that you and your surgeon are on the same page. He should know the exact need for surgery, as well as your compliance issues during the actual procedure. Never wait for the insurance company to ask questions. Respond when your surgeon submits a request for authorization.
Does Aetna Cover Gastric Sleeve Surgery?
If the pouch is stretched, the staple line fails, the band slips or the bypass doesn’t work, you should have pre-op testing to prove these allegations. Whether an MRI, CT scan or endoscopy, you must have the results before applying for certification. Likewise, you should provide your surgeon with a general description of your compliance over the years, including diet and exercise history.
Chances are that your body mass index (BMI) has dropped several times and you no longer have significant co-morbidities. In this case, you’re going to make sure the carrier knows that if the revision isn’t approved, it’s only a matter of time before your BMI rises even higher and your co-morbidities return. If your request includes a new type of surgery, perhaps one that didn’t exist at the time of your original surgery, make sure reasons why this surgery is right for you are included in the surgery request. These advance strikes can get you approved by answering the insurance company’s questions before they are asked.
I know what you’re thinking. Let’s say my insurance company no longer covers or does bariatric or weight loss surgery. Well, in that case you are going to argue two things. First, that weight loss surgery must be a covered expense because it is used to treat co-morbidities other than obesity, such as diabetes or hypertension. And secondly, it is a request to correct a failed procedure that may cause significant problems in the near future and as such is not for obesity or weight loss. The latter is a tough argument, but one that is successfully made. So remember, just like your request for your original surgery, you must document your claim. And, of course, never leave.
Gary Viscio, Esq., is an attorney specializing in obesity surgery, reimbursement and coverage, as well as appeals for obesity discrimination denials. In July 2003, she underwent weight loss surgery and has lost over 160 pounds to date. He is a member of the Board of Directors of the Obesity Action Coalition, the Obesity Help Advisory Panel, and the National Spinal Cord Injury Association. He has handled insurance litigation matters for nearly 15 years.
What Is A Gastric Sleeve Surgery?
Comprehensive obesity care requires teaming up with a competent and compassionate medical professional. Find the right healthcare provider to talk about your weight and health at ObesityCareProviders.com. According to the Centers for Disease Control and Prevention (CDC), about 40% of American adults are obese. Obesity increases the likelihood of major health risks and can significantly reduce a person’s quality of life. Thus, shortening the lifespan. When fighting obesity, weight loss surgery – such as bariatric surgery – is one of the most effective approaches.
If you are a Medicare beneficiary hoping to receive bariatric surgery, you may be able to get coverage through your Medicare plan. Medicare coverage for bariatric weight loss surgery is available to beneficiaries who meet specific criteria. Although not all bariatric weight loss surgeries are covered, there are several options available to people with Medicare.
The demand for Medicare coverage of bariatric weight loss surgery continues to grow as the obesity rate of Americans continues to rise. Medicare coverage includes various bariatric weight loss surgeries to treat obesity and related health conditions, after meeting various requirements and obtaining approval from a licensed physician.
Although Medicare pays for bariatric procedures, the program decides to deny or approve benefits on a case-by-case basis. To be considered for approval, bariatric surgery must first be approved by the FDA. However, even after a Medicare beneficiary meets the requirements for bariatric surgery, Medicare coverage is still at the discretion of their doctor and Medicare.
Does Medicare Cover Weight Loss Surgery?
Not all situations in life are the same. Unfortunately, this means that coverage can vary from person to person. However, bariatric surgery is often considered medically necessary because many conditions stem from obesity.
Although Medicare covers many bariatric weight loss surgeries, it does not cover all surgeries. Below is a list of weight loss surgeries that receive coverage from Medicare:
Outside of this list of procedures, Medicare coverage for weight loss surgery is limited and may not be available. Gastric bypass
Gastric bypass is a medical procedure that divides the stomach into smaller segments to restrict calorie intake. Medicare may cover gastric bypass surgery after screening for obesity along with a BMI test and counseling. However, you must meet the criteria for morbid obesity and meet any deductible costs.
Insurance Cover: Will My Insurance Cover Weight Loss Surgery?
Medicare covers sleeve gastrectomy surgery when your doctor deems it medically necessary and you meet bariatric requirements.
Commonly known as gastric sleeve surgery, this procedure removes and separates approximately 85% of the stomach. Then, the remainder is molded into a tubular shape that cannot hold much food or liquid.
Patients lose an average of 65% of excess weight after gastric sleeve surgery, making it one of the fastest growing bariatric surgeries. Duodenal switch
Duodenal switch is a new surgery option available with Medicare coverage. Like the gastric sleeve option, DS removes a large portion of the stomach.
Gastric Sleeve Surgery
Medicare covers duodenal switch surgery, although finding a surgeon who performs the procedure can be challenging. Many surgeons are not familiar with this surgery, so finding the right doctor is more challenging. lap-band
Lap-band surgery is a type of gastric bypass that divides your stomach into an upper and lower section. Under the right circumstances, Medicare will cover lap band surgeries. The cost depends on many factors. Talk to your doctor and ask how much surgery might cost so you can plan for out-of-pocket costs. Medicare requirements for bariatric surgery coverage
To be considered a candidate for bariatric weight loss surgery, you must meet all of the above requirements. Even if you meet each requirement, Medicare does not have to approve your surgery. Each approval is on a case-by-case basis.
Medicare approval of bariatric weight loss surgery can be a complicated process. From the first visit to medical clearance, it can take three to four months for Medicare to approve the surgery. However, this time frame may vary depending on health conditions and severity.
Cigna Requirements Help
Comorbidities are health conditions that are related to another health problem. Sometimes, this means that one health problem causes another problem. In the case of bariatric surgery, comorbidities refer to any condition arising as a direct result of morbid obesity. Medicare lists major bariatric surgery-approved comorbidities: type 2 diabetes, sleep apnea, hypertension, joint or back pain, soft tissue infections, and more.
If you are morbidly obese and not experiencing any of the above diagnoses, you may still be eligible for bariatric surgery. However, you must prove tolerance due to obesity. Average cost of bariatric weight loss surgery with Medicare
In the United States, the average cost of bariatric weight loss surgery can range from $25,000-$30,000. Medicare will be responsible for Part A and Part B, along with those who meet eligibility requirements and are accepted for coverage. Medicare Part A and Part B deductibles, Medicare Part B 20% coinsurance, and any coinsurance or deductible payments for Medicare
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