Weight Loss Surgery Medicare Guidelines

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If you are covered under Medicare, please read the following Surgery Requirements and print this form and bring to your family Doctor.

A. Covered Procedures that My Bariatric Solutions does:

  1. Laparoscopic Adjustable Gastric Band

B. To qualify for weight loss surgery Medicare requires that the patient complete ALL 4 of the following requirements listed below:

(From Texas Medicare Bariatric Surgery Guidelines)

1. Have a Body Mass Index (BMI) of 35 or greater at the time of surgery.

(Check your body mass index (BMI).

2. Have at least ONE of the following diagnosed health conditions

  • Type II diabetes mellitus (by American Diabetes Association diagnostic criteria).
  • Refractory hypertension (defined as blood pressure of 140 mmHg systolic and/or 90 mmHg diastolic despite medical treatment with maximal doses of three antihypertensive medications).
  • Refractory hyperlipidemia (acceptable levels of lipids unachievable with diet and maximum doses of lipid lowering medications).
  • Obesity-induced cardiomyopathy.
  • Clinically significant obstructive sleep apnea.
  • Obesity-related hypoventilation.
  • Pseudotumor cerebri (documented idiopathic intracerebral hypertension).
  • Severe arthropathy of spine and/or weight-bearing joints (when obesity prohibits appropriate surgical management of joint dysfunction treatable but for the obesity).
  • Hepatic steatosis without evidence of active inflammation.

3. Have been previously unsuccessful with medical treatment for obesity (documentation must be provided by family doctor of failed diet attempts-records can be sent to 940-626-8684).

4. Psychological Evaluation

C. Prior to your initial consult with My Bariatric Solutions physician, the following pretesting requirements must be completed:

  • If patient has BMI greater than 50, the primary care physician needs to order a sleep study to rule out or confirm diagnosis of obstructive sleep apnea and appropriate treatment needs to be initiated.
  • Cardiac clearance to include a stress test and echocardiogram (pre-operative testing deemed appropriate by the cardiologist) if any of the following apply:
    • If patient has a BMI equal to or greater than 40  
    • If patient has a diagnosis of hypertension and/or diabetes
    • If pt has family history of heart disease/heart attack in persons younger than 50 years of age 

D. Contraindications to Bariatric Surgery according to Medicare and My Bariatric Solution guidelines

  • Prohibitive perioperative risk of cardiac complications due to cardiac ischemia or myocardial dysfunction.
  • Severe chronic obstructive airway disease or respiratory dysfunction.
  • Non-compliance with medical treatment of obesity
  • Failure to cease tobacco use
  • Psychological/psychiatric conditions:
    • Schizophrenia, borderline personality disorder, suicide ideation, severe or recurrent depression, bipolar affective disorders
    • Mental retardation
    • Any other psychological/psychiatric disorder that in the opinion of the psychologist/psychiatrist imparts a signification risk of psychological/psychiatric decompensation or interference with the long-term postoperative management.