X-POST Useful Medicare PA insurance nugget
In my quest for prior authorization to have excess skin removed from my thighs, I got this little nugget of information from Medicare - I'm going to check with my replacement plan to find out if it works this way with them:If the surgery is done on an outpatient basis - insurance *cannot* be submitted for prior autthorization retroactively. GUARANTEES non-coverage.
If the surgery is done INPATIENT - including hospital stay for at least 24 hours post op - retroactive PA can be done *up to 90 days post-procedure* They could conceivably still deny, but I'm thinking if inpatient is necessary, they would be nuts not to! If they did, you could still appeal!
HW 405/SW 397/CW 138/GW 160 Do the research! Check the stats!
The DS is *THE* solution to Severe Morbid Obesity!
Jackie-
OK...I checked with my AARP Medicare Complete plan, which is administered through United Health Care, and they say they require prior authorization for *any* surgery. This may or may not be true for straight Medicare through the government (part A and Part B).
"Medical Necessity" is the key for both bariatric and reconstructive surgery. I have that from my PCP and dermatologist, for the thigh reconstruction with the infections and such. Back when I had my DS (2009), it and the RNY were the only two surgeries Medicare paid for.
I have had a Medicare Complete Plan since after the first year I had Medicare. I get more, and my medications for Lupus and Fibromyalgia run way less out of pocket. I can add on dental and vision, too! Heck, majority of my income goes to medical out of pocket/co-pays and prescriptions and vites anyway! I thank God I can even afford to eat pay rent and utilities, and put gas in the car. I don't qualify for Food Stamps or SNAP, or whatever they call it now. "Income" is too "high".
Same for energy assistance.
OK...I checked with my AARP Medicare Complete plan, which is administered through United Health Care, and they say they require prior authorization for *any* surgery. This may or may not be true for straight Medicare through the government (part A and Part B).
"Medical Necessity" is the key for both bariatric and reconstructive surgery. I have that from my PCP and dermatologist, for the thigh reconstruction with the infections and such. Back when I had my DS (2009), it and the RNY were the only two surgeries Medicare paid for.
I have had a Medicare Complete Plan since after the first year I had Medicare. I get more, and my medications for Lupus and Fibromyalgia run way less out of pocket. I can add on dental and vision, too! Heck, majority of my income goes to medical out of pocket/co-pays and prescriptions and vites anyway! I thank God I can even afford to eat pay rent and utilities, and put gas in the car. I don't qualify for Food Stamps or SNAP, or whatever they call it now. "Income" is too "high".
Same for energy assistance.
HW 405/SW 397/CW 138/GW 160 Do the research! Check the stats!
The DS is *THE* solution to Severe Morbid Obesity!
(deactivated member)
on 5/27/12 4:04 am
on 5/27/12 4:04 am
On May 27, 2012 at 6:58 AM Pacific Time, JazzyOne9254 wrote:
In my quest for prior authorization to have excess skin removed from my thighs, I got this little nugget of information from Medicare - I'm going to check with my replacement plan to find out if it works this way with them:If the surgery is done on an outpatient basis - insurance *cannot* be submitted for prior autthorization retroactively. GUARANTEES non-coverage.
If the surgery is done INPATIENT - including hospital stay for at least 24 hours post op - retroactive PA can be done *up to 90 days post-procedure* They could conceivably still deny, but I'm thinking if inpatient is necessary, they would be nuts not to! If they did, you could still appeal!
Why should taxpayers pay for cosmetic surgery?
I was a taxpayer for 30+ years, (I've had a job since I was 15) until in 2005, I became disabled with lupus and fibromyalgia. Prednisone to treat the lupus helped push my weight up to over 400 pounds.
I had my DS ion 2/25/2009, and it is one tool in my strategy to get off disability and back to work.
Check my ticker. I have loose, hanging thigh skin, that must be confined by a custom fit, medical compression garment,($1750 out of pocket) so that I can ambulate (walk), and fit into clothing. The loose skin also presents a hygiene problem, and the garment friction (when I lose weight, and have to have another one made) has caused cellulitis (infection of the fat cells under the skin) on more than one occasion. Doc's are fearing antibiotic resistance and posssible sepsis when/if that occurs. Also, the hygiene routine is extreme.
My former occupaton (radio news reporter)is too physical for me to return to with lupus and fibromyalgia, so I am In Vocational Rehabilitation. When I'm done with the required coursework and internship, I will qualify to sit for the national Registered Dietitians exam, pass it, become a RD, with a specialty in bariatric nutrition.
I paid taxes, too. Probably for more years than you've been alive. Those years earned me the right to utilize Social Security and Medicare if/when I needed to.
I think you can tell I'm not just sucking up "taxpayers" money.
Don't make borad assumptions about people. That's called stereotyping, which is a key component of prejudice.
I had my DS ion 2/25/2009, and it is one tool in my strategy to get off disability and back to work.
Check my ticker. I have loose, hanging thigh skin, that must be confined by a custom fit, medical compression garment,($1750 out of pocket) so that I can ambulate (walk), and fit into clothing. The loose skin also presents a hygiene problem, and the garment friction (when I lose weight, and have to have another one made) has caused cellulitis (infection of the fat cells under the skin) on more than one occasion. Doc's are fearing antibiotic resistance and posssible sepsis when/if that occurs. Also, the hygiene routine is extreme.
My former occupaton (radio news reporter)is too physical for me to return to with lupus and fibromyalgia, so I am In Vocational Rehabilitation. When I'm done with the required coursework and internship, I will qualify to sit for the national Registered Dietitians exam, pass it, become a RD, with a specialty in bariatric nutrition.
I paid taxes, too. Probably for more years than you've been alive. Those years earned me the right to utilize Social Security and Medicare if/when I needed to.
I think you can tell I'm not just sucking up "taxpayers" money.
Don't make borad assumptions about people. That's called stereotyping, which is a key component of prejudice.
HW 405/SW 397/CW 138/GW 160 Do the research! Check the stats!
The DS is *THE* solution to Severe Morbid Obesity!
I'm sorry you had to defend your position here but I thank you for sharing this. I bet it will help many others in the same boat. I cant imagine the daily difficulties you deal with. I wish you success in your quest.
5.0 cc in a 10cc lapband (four fills) 1 unfill of .5cc on 5/24/2011.
.5 fill March 2012. unfill of .25cc May 2012. Unfill of .5cc June 2014.
Still with my lapband with no plans for revision. Band working well since
last small unfill.
HW: 267lbs- size 22-24 LW:194lbs CW:198lbs Size 14-16
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