Looking for help in getting gastric bypass surgery on medicare Here's what I found on Medicare guidelines & coverage of Bypass Surgery:
Obesity, Medicaid and Medicare
Medicaid does not cover obesity. Under Medicare, hospital and physician services to treat obesity are excluded unless the treatment is for certain co-existing conditions, and then it is considered on a case by case basis. Medicaid is a government program that provides health insurance to qualified individuals whose income level is below a certain point. Recipients of Medicaid are primarily women and children who are poor and members of minority groups. Given the high prevalence of obesity among those populations, it could be presumed that many Medicaid recipients are likely to have obesity. Medicare provides health insurance coverage to elderly citizens and disabled Americans who qualify by meeting criteria of the Social Security Administration (SSA) and completing a two-year waiting period.
Medicaid
In 1990, Congress enacted the Omnibus Budget Reconciliation Act (OBRA), which funds state programs to provide pharmaceutical products to Medicaid recipients.
A State may choose to exclude or restrict drugs or classes of drugs, or their medical uses for certain purposes. A State choosing to include outpatient drugs within its Medicaid program must cover, for their medically accepted indications, all Food and Drug Administration (FDA) approved prescription drugs of manufacturers that have entered into drug rebate agreements, with a few limited exceptions.
Exceptions include drugs when used for: anorexia, weight loss or weight gain; to promote fertility; for cosmetic purposes or hair growth; for the symptomatic relief of cough and colds; or to promote smoking cessation.
As a result of OBRA, the Department of Health and Human Services ordered states to cover Viagra for the treatment of erectile dysfunction while continuing to exclude anti-obesity agents.
Medicare
In July 2004, the Department of Health and Human Services eliminated Medicare policy previously stating that obesity was not a disease. The Medicare Coverage Manual defines obesity and the justification for its treatment coverage by stating that:
Obesity may be caused by medical conditions such as hypothyroidism, Cushing鹿s disease, and hypothalamic lesions or can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension. Services in connection with the treatment of obesity are covered services when such services are an integral and necessary part of a course of treatment for one of these medical conditions. However, program payment may not be made for the treatment of obesity unrelated to such a medical condition since treatment in this context has not been determined to be reasonable and necessary.
This does not change any of the current coverage determinations. Treatments for obesity alone remain non-covered and coverage for treatments of diseases resulting in or exacerbated by obesity remain unchanged.
Individuals wishing to modify current coverage determinations are encouraged to request a National Coverage Determination on each specific treatment. The web site of the Centers for Medicare and Medicaid Services offers guidance on the Medicare Coverage Process Regulations.
For more information on the recent changes in Medicare policy, read the AOA's Medicare and Obesity: Frequently Asked Questions.
Medicare鈥檚 limited coverage of obesity is difficult to understand when considering that it does cover services such as inpatient and outpatient alcohol detoxification and rehabilitation, inpatient and outpatient drug rehabilitation, and services for sexual impotence. It also covers chemical aversion therapy for the treatment of alcoholism even though the FDA has not approved the drugs commonly used in chemical aversion therapy for this application.
Supplemented Fasting
******** I couldn't find any listing for a National Institute for Gastric Bypass Surgery. I would suggest calling a local hospital where you live & talking to a social worker about any Bariatric programs or Physician referrals she might be able to give you. Hopefully, you can then call a Bariatric Surgeon's office & talk with a nurse to see if you meet any possible case requirements to proceed in getting coverage under Medicare Guidelines for this surgery. Good luck!
Edit: I did find a site you can at least find a Bariactric Surgeon in your area. Go to www.asbp.org & then just click on your state & you can pick from a list of local surgeons. Their office staff should be able to answer your medicare question. You also might ask to see if you would qualify for any clinical trials that might be taking place in your area. |
