Does Medicare Cover Bariatric Surgery?

Obesity is a leading cause of numerous other health concerns. Unfortunately, many people struggle to overcome obesity with traditional weight loss techniques. Bariatric surgery allows individuals to improve their overall health while losing weight.

Bariatric surgery, often called weight loss surgery, removes or restricts part of your stomach to aid in weight loss by preventing food absorption. There are many different types of bariatric surgeries, and Medicare covers many of them, subject to eligibility.

Bariatric Surgeries Covered by Medicare

Each Medicare plan and individual’s circumstances are different. However, most Medicare plans cover the following bariatric surgeries for eligible individuals:

Gastric Bypass Surgery: This procedure divides the stomach to create a small pouch to restrict the amount of food a patient can eat. The small intestine is bypassed to reduce the absorptive surface area in the small intestine.

Gastric Sleeve Surgery: In this procedure, a large portion (approx. 75-80%) of your stomach is removed from the abdomen, and only a small pouch is left to process food.

Duodenal Switch: This surgery combines the removal of a portion of your stomach the same way as a gastric sleeve, then bypassing part of the intestine, which combines to reduce the amount of food consumed.

LAP-BAND Surgery: This surgery places a band with pillow-like chambers containing saline around the upper stomach. Saline is injected into or removed from the band to adjust restriction.

Revision surgeries (correction of previous surgeries): Revisions or conversions, secondary bariatric procedures, may not be covered by Medicare. Band removals for slippage or severe medical complications may warrant coverage.

Regardless of the procedure that you and your bariatric surgeon determine is right for you, eligibility requirements must be met for Medicare coverage.

Medicare Eligibility Requirements for Bariatric Surgery

Because bariatric surgery does require long-term lifestyle changes, a thorough determination of eligibility must be made before surgery and before Medicare provides coverage.

Medicare Eligibility Requirements include:

• A body mass index (BMI) of 35 or more
• A minimum of one other serious health concern related to obesity. Examples include diabetes, high blood pressure, obstructive sleep apnea, and more.
• A referral letter from your doctor
• Medical or psychological tests or evaluations as deemed necessary.
• Documented proof of unsuccessful participation in a medically supervised weight loss program

It could take some time to complete all of the requirements for Medicare eligibility for bariatric surgery. That’s why it’s crucial to know what’s required at the beginning stage of your journey.

Medicare Bariatric Surgery Coverage and Out-of-Pocket Costs

Medicare is unique, containing Parts A through D, and with additional Medicare Supplement Plans available. However, when you break it all down, out-of-pocket costs are much the same as traditional insurance plans.

Medicare Part A helps cover inpatient hospital expenses. Part B applies to outpatient procedures, and Part D covers prescription medications you may need throughout your recovery. If you have a Part C Medicare Advantage Plan you may be required to get prior authorization. Part C works the same as traditional insurance plans.

Potential Out-of-Pockets expenses with Medicare include:

Deductibles. Your Medicare plan has specified deductibles for each part. Those deductibles must be met on an annual basis. The amount you owe will depend on your plan and previous deductible output in the current policy year before surgery.

Co-Insurance. This is the amount of shared financial responsibility between you and Medicare. While Medicare will cover the more significant amount, your plan documents list the percentage you must pay.

Medicare Supplement policies exist to help fill in some of those out-of-pocket costs. Each Medicare Supplement policy is different. Refer to your plan documents or call their customer service center for more information specific to your plan.

Medicare Advantage plans will have lower out-of-pocket costs if using a network provider.

Appealing a Medicare Denial of Bariatric Surgery Coverage

Traditional Medicare coverage denials occur after surgery (advantage plans offer pre-approval), and many patients don’t understand why. The usual (and normal) response is to feel frustrated and concerned.

Denial of bariatric coverage can be for various reasons, some of which are easily corrected. Start by contacting your surgical practice for assistance. They will help you work with Medicare to determine the reason for denial and whether a quick solution is available.