Medicare Guidelines

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

1. Covered Procedures that My Bariatric Solutions does:
   1. Laparoscopic Roux-en-Y Gastric Bypass
   2. Laparoscopic Adjustable Gastric Band
2. NON-Covered Surgical Procedures:
   1. Laparoscopic Sleeve Gastrectomy

To qualify for weight loss surgery, Medicare requires that the patient complete All 3 of the following requirements listed below:

1. Have a Body Mass Index (BMI) of 35 or greater at the time of surgery. Click here to check your 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.

   Though the conditions listed above need not be immediately life-threatening for Medicare to cover bariatric surgery, the condition must not be trivial or easily controlled with non-invasive means (such as medication) and must be of sufficient severity as to pose considerable short- or long-term risk to function and/or survival. Consideration of the risk-benefit for each individual patient must be used to determine that surgery for obesity is the best option for treatment for that patient and no contraindications to bariatric surgery may exist. (From Texas Medicare Bariatric Surgery Guidelines)

3. Complete a 6 month Physician Supervised Weight Loss Program proximate to the time of surgery.
   Medicare requires that the program include a physician-supervised nutrition and exercise program: Including dietitian consultation, appropriate calorie diet, increased physsical activity and behavioral modification, documented in the medical record. This physician-supervised nutrition and exercise program must meet ALL of these criteria:
   • Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with appropriately trained dietitians and/or nutritionists.
   • Nutrition and exercise program(s) must be for a minimum cumulative total of approximately six months, with participation in one program for at least three consecutive months.
   • Within the two years prior to surgery, an attending physician who supervised the patient's participation must document participation in a physician-supervised nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may not be supervised by the surgeon who will perform the surgery. Note: A physician's summary letter is not sufficient documentation. Documentation should include medical records of the physician's contemporaneous assessment of the patient's progress throughout the course of the nutrition and exercise program and must include, at a minimum, summary statements of the patient's course prepared by the nutritionist, dietitan and exercise program director. For patients who participate in a physician-administered nutrition and exercise program, program records documenting the patient's particiipation and progress may substitute for physician medical records.
   • Physician documentation that the patient has achieved a weight loss of 20 lbs or at least 10% of body weight during the course of the program.