BMI 47.4 with Medicare. .

[MyNewLife]

Ok. My roomie wants the DS but because she doesn't have a BMI of 50, they only offer her the RNY.

I had my DS with Dr. Cooper in Seymour, IN two years ago and I love the man. I stated I would be happy to pursue the insurance company to get approval and fight the good fight. He basically said that even with an approval, the insurance company does not have to pay. Basically, he wasn't going to take the risk for himself or the hospital of non-payment.

Has anyone fought the good fight with Dr. Inman up in Northern Indiana. Is she willing to pursue the insurance companies on behalf of the patient.

My roomie has degenerative disk disease, migraines and a couple of other co-morbids. She has developed diabetes in the last 6 months. She also suffers from Fibromyalgia and low thyroid. She is 5'2" and weighs 259.

Anyone been through this with Dr. Inman?

Thanks!

Me

 

[southernlady]

Okay, see these posts:
http://bariatricfacts.org/threads/cms-center-for-medicare-medicaid-service-wls.316/
http://bariatricfacts.org/threads/cms-center-for-medicare-medicaid-service-wls-standards.317/

I had the DS at a 3.2 BMI, but had diabetes.

Medicare does NOT pre-approve. However a Medicare Advantage policy may issue a pre-approval. I know mine did. (BCBSTN) But they got picky about my going outside the state to have my DS.

Good luck in helping her fight. IF she has Degenerative Disk disease, the RNY IS CONTRAINDICATED since she requires the ability to use NSAIDS.

 

[MyNewLife]

I read but why would Dr. Cooper be so adamant that it has to be a BMI of 50. Twice she's almost went for the RNY because she is so miserable and then chose to not have it for fear of the failings of the RNY (no pylorics, etc). She's tried to lose the weight tons of ways and that hasn't worked (surprise). Has anyone gotten the DS from the Inman group with Medicare and a BMI under 50?

Thanks.

 

[southernlady]

I had issues finding someone willing to do the DS on a lightweight...Most of the ones I contacted that actually do the DS were not willing to tackle someone under a 50 BMI.

First, she needs to make sure, IF she does not have Medicare A/B but has the C option http://medicare.com/medicare-coverage-basics/medicare-part-c.html

Then she needs to get out her Evidence of Coverage book and see what it says. Example, my BCBSTN Medicare policy said it followed Medicare rules (they all say that, btw) but if it's not a Medicare C policy but an A/B policy, she is covered based on those memos I listed.

IF she is on a part C plan, she needs to contact the Customer Service dept listed on her card.

And finally she needs a sit down with Dr. Cooper and be armed with the Medicare information as well as any studies about diabetes and NSAIDS. And BLUNTLY ask why, given these things, is the RNY being pushed.

 

[DianaCox]

Medicare does NOT require a BMI of 50 for the DS. Period. Any surgeon who is imposing this requirement on a Medicare patient is doing it for his or her own reasons, without regard to the Medicare guidelines.

 

[MyNewLife]

Thanks, Diana. That's what I was hoping to hear. I think we're traveling to Dr. Inman. I doubt we'll be able to get her but do we know of any of her associates that are good? This might be the wrong sub-forum to ask on but then you know me

 

[Spiky Bugger]

Is this straight up Medicare? Or like Liz mentioned, a Medicare HMO or an "advantage" policy? You might have to act like a bulldozer if it isn't "just" Medicare.

HOWEVER...why are YOU doing the research? A DS patient has to be very proactive, sometimes, even to survive. If your roomie does not present as someone who can speak for herself, maybe the doctor in question is (using an unethical approach for a good reason and) trying to keep her from having a surgery she can't handle.

 

[MyNewLife]

She is disabled on SSDI, she has been with me for almost 10 years now. She is more than capable of compliance to the diet and she takes almost as many scripts as she will be taking vites so that is not a concern, she's helped me through my surgery and all my ups and downs, she is not capable of doing the research nor fighting the fight but I am. She has just a red/white/blue medicare card but also has what is called "extra help" where Indiana state medicaid helps with co-pays and premiums only. They are supposed to supplement whatever is covered by Medicare. Dr. Cooper was more than happy to give her an RNY and she passed the psych eval with flying colors (I will say that eval is intense as opposed to some of the others where people just go in and talk, the psych testing alone with Doc Cooper takes over an hour and then you do the talking).

So, looks like we'll be going up north, just wish I knew someone under 50 that had gone to Inman's office.

Thanks!!!

 

[Spiky Bugger]

Good news, then, on her ability to deal with living with the DS.

I'm no pro on this, but it sounds like the Medi-Medi (Medicare-MediCal, California's Medicaid) my cousin's disabled son has in California.

I only know that it exists, and that some doctors who take Medicare alone won't take Medi-Medi. That leads me to wonder if it's the add-on help that might be causing the problem for your roomie. Maybe @DianaCox knows.

I'm just suggesting it in case someone here knows how the combo of insurances impacts eligibility.

(Hubby is a Hoosier...way down south along the Ohio River...we were there last year...probably won't be back for a while. He's all citified now and his family is from a rural area...they have nothing in common but DNA.)

 

[JackieOnLine]

I hope she is able to get what she needs - good for you for helping her. :038:

 

[Paula]

I'd find another surgeon because the BMI thing sounds more surgeon preferred than Medicare's guideline of a BMI of 35 or greater. The trouble is finding a surgeon who takes Medicare. An example is Rabkin in California does not. She would just have to ask Inman's office if Medicare is accepted insurance.

It sounds to me like she has straight Medicare. The extra help part means that the State of Indiana is paying her Part A premium plus any compayments (like the $ she would pay when she goes into the hospital for her DS...in 2012, I paid $1152 to St. Marks when I had my DS revision), but it doesn't necessarily mean she has Indiana's state insurance as a secondary billable insurance. CMS has a criteria list for covering bariatric surgery, though Medicare does not preapprove anything (as someone else mentioned). My surgeon just made me sign a paper saying that if Medicare denied the claim, Id be responsible for the full bill.

 

[MyNewLife]

I called Inman's yesterday and they do take her insurance. She goes next week to get a referral and then they will give her an initial appt. Thanks guys!!!

 

[Parousia]

An extra 5 pounds would put her BMI up to 50. I suggest that on the day she has her appointment she has plenty to eat and drink beforehand, and wear some heavy clothing. Just in case . She may well be able to add on the extra weight that way, if necessary.

 

[Terri]

Inman is only Dr. in Indiana that does the DS. This may be why Cooper wasn't recommending, because he doesn't do it.

 

[MyNewLife]

Dr. Cooper out of Seymour does the DS. He is not on the vetted list but I loved him as a surgeon and adored his staff. I don't like how he handled my roomies BMI restrictions, he should have said he "personally" didn't do the DS on BMI's under 50 or he may be under the mistaken belief that Medicare won't pay. I'm not sure but it's the ONLY negative thing I can say about him. Love him as a man and a surgeon. He used the DaVinci robotic machine with me...I thought that was way kewl