Does Medicare cover bariatric surgery?

Bariatric surgery, commonly known as weight loss surgery, alters person’s digestive process within the gastrointestinal (GI) tract to assist the person in losing weight. There are 2 types of bariatric surgical techniques: restrictive and malabsorptive. These 2 techniques can also be combined to form a third technique. Most procedures are performed using a laparoscopic or open approach.

• Restrictive procedures: Reduce the stomach size thus decreasing the amount of food the stomach can hold
• Malabsorptive procedures: Limit the amount of nutrients and calories that the body can absorb

Some of the common types of Medicare bariatric surgeries include gastric bypass, lap band surgery and gastric sleeve surgery.

Gastric bypass surgery

This common malabsorptive weight loss surgery is also known as Roux-en-Y gastric bypass (RYGB). In this procedure, a small stomach pouch is created to restrict food intake. The rest of the stomach is bypassed via a Y-shaped segment of the small intestine, which reduces the amount of calories and nutrients the body absorbs.

LAP-BAND^® surgery

This surgery is defined as “Laparoscopic adjustable gastric banding (LAGB) (i.e., LAP-BAND^®).” This common weight loss procedure involves the placement of a hollow band around the upper end of the stomach, creating a small pouch and a narrow passage into the larger remainder of the stomach. The band is inflated with saline solution, which can be increased or decreased over time to alter the size of the passage.

Gastric sleeve surgery

This weight loss surgery is also commonly known as “vertical sleeve gastrectomy” or “sleeve gastrectomy” (open or laparoscopic). This procedure involves the removal of the greater curvature of the stomach and approximately 80% of the stomach volume. While pyloric sphincter and stomach functions are preserved, the remaining stomach resembles a slender curved tube.

Understanding the qualifications for getting weight loss surgery

According to the National Coverage Determination (NCD) for bariatric surgery, you may be eligible for bariatric surgery if:¹

• You have a body mass index (BMI) greater than 35
• You have at least 1 other condition related to obesity
• You have been previously unsuccessful with medical treatment for obesity

Estimating the cost of getting bariatric surgery

It’s hard to know exactly how much your weight loss surgery may cost because it’s difficult to determine what services you may need during and after your procedure. If you are at an inpatient hospital, then Medicare Part A will help cover costs. If your weight loss surgery is performed at an outpatient center, then Medicare Part B will assist with these costs.

Since Original Medicare (Part A and Part B) doesn’t cover the entire cost of the surgery, you can also consider buying a Medicare Supplement (Medigap) plan to help offset any out-of-pocket expenses you may incur, such as some of the deductibles, copayments or coinsurance.

Medicare Advantage (MA) plans must cover the same benefits as Original Medicare, but many offer additional benefits such as prescription drug coverage and an annual out-of-pocket maximum.

Before you get weight loss surgery it is always best to:

• Talk to your doctor about all of your options
• Clarify with the hospital or facility conducting your procedure how much you might pay for the surgery and aftercare
• Be aware of how much you may owe on your deductible, as this amount needs to be satisfied before Medicare can start to pay
• Know that copayments may still apply for the care you receive

 

Note: This material is provided for informational use only and should not be construed as medical advice or in place of consulting a licensed medical professional. You should consult your doctor to determine what is best for you.