Question

It is a fact that Medicare does not cover all procedures. It is important that patients know this and know what they are responsible for in terms of payment. An ABN (Advance Beneficiary Notification) is a form that takes care of this issue.

You have a patient that would like to have Bariatric surgery for weight loss. Obviously, the patient is over 65 and covered by Medicare. Please research the State of Montana and CMS to see if the Medicare system will cover this. What is an approximate cost, are there certain conditions to be met, what exactly is covered.

Then you will fill out an ABN for this patient (please select a name and information)

1. A short report defining the surgery and what is covered under Medicare.

2. An ABN for a patient wanting this surgery.

Answer 1

1. Bariatric Surgery or Weight-loss Surgery is done on people who are Obese and with some Obesity related Complications.

The Indications of this Surgery are-

• BMI > 35 kg/m^{​​​​​​2} with "obesity related Complications" Such as Hypertension,Type 2 Diabetes Mellitus , CAD , Osteoarthritis , Pickwickian Syndrome etc.
• Obese Patient: Who failed to loose Weight despite - Lifestyle modification, pharmacotherapy and Psychotherapy

Various Procedures Done for this Surgery are -

• Purely Malabsorptive- Biliopancreatic division and Duodenal Switch
• Restrictive + Malabsorptive-  Rou-en Y - gastrojejunostomy
• Restrictive - Sleeve Gastrostomy , Laparoscopic adjustible gastric banding , Intragastric balloon Placement.

Medicare coverage Part- A

Medicare Part A hospital insurance covers inpatient hospital care, skilled nursing facility, hospice, lab tests, surgery, home health care.

Medicare Coverage Part-B

• screening for cancer, depression, and diabetes
• ambulance and emergency department services
• influenza and hepatitis vaccinations
• electrocardiograms (ECGs)
• medical equipment
• some drugs, diabetes supplies, and some prescriptions for eyewear

Medicare Coverage Part- C

Medicare Part C plans, also called Medicare Advantage plans, are supplemental plans that provide more coverage for an additional cost. They are private insurance plans approved by Medicare that fill in the gaps in services and hospital care. People with Medicare Part C must already be enrolled with Parts A and B.

Under these plans, you can get prescription drug coverage, dental and eye coverage, and other benefits.

Medicare  ​​​​Coverage Part-D
Medicare Part D is the plan that covers prescription drugs not covered by Part B, which are typically the kind of medications that need to be administered by a doctor, like an infusion or injection. This plan is optional, but many people choose to have it so their medications are covered.

2.

Patient Name is Mr.Grey and he needs Bariatric surgery to be done which may or may not be included in Medicare whose estimated cost is around $20,000 to $25,000.