Medicare Guidelines

My Bariatric Solutions > Medicare Guidelines

Covered Procedures that My Bariatric Solutions does:

Laparoscopic Adjustable Gastric Band and Gastric Sleeve

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)

  • Have a Body Mass Index (BMI) of 35 or greater at the time of surgery. Check Your Body Mass Index (BMI).
  • 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.
  • 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).
  • Psychological Evaluation

Contraindications to Bariatric Surgery according to Medicare Bariatric Surgery Guidelines and My Bariatric Solution guidelines

Surgery for severe obesity is a major surgical intervention with a risk of significant early and late morbidity and perioperative mortality. Surgery for severe obesity is not covered in the presence of absolute contraindications, including the following:

  • 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 or treatment of other chronic medical condition.
  • Failure to cease tobacco use.
  • Psychological/psychiatric conditions:
    • Schizophrenia, borderline personality disorder, suicidal ideation, severe or recurrent depression, or bipolar affective disorders with difficult-to-control manifestations (e.g., history of recurrent lapses in control or recurrent failure to comply with management regimen).
    • Mental retardation that prevents personally provided informed consent or the ability to understand and comply with a reasonable pre and post-operative regimen.
    • Any other psychological/psychiatric disorder that, in the opinion of a psychologist/psychiatrist, imparts a significant risk of psychological/psychiatric decompensation or interference with the long-term postoperative management.
Note: A history of or presence of mild, uncomplicated and adequately treated depression due to obesity is not normally considered a contraindication to obesity surgery.
 

  • History of significant eating disorders, including anorexia nervosa, bulimia and pica (sand, clay, or other abnormal substance).
  • Severe hiatal hernia/gastroesophageal reflux (for purely restrictive procedures such as LAGB).
  • Autoimmune and rheumatological disorders (including inflammatory bowel diseases and vasculitides) that will be exacerbated by the presence of intra-abdominal foreign bodies (for LAGB procedure).
  • Hepatic disease with prior documented inflammation, portal hypertension or ascites.