Medicare Coverage for Bariatric Surgery

If you’ve been researching bariatric surgery and are on Medicare, you might wonder whether your procedure will be covered, how much you’ll need to pay out of pocket, and what hurdles you may need to jump. Navigating the Medicare system can feel overwhelming, but rest assured, it’s not as complicated as it appears. Here’s a straightforward look at how Medicare can help with the cost of weight loss surgery and what you can expect along the way.

Does Medicare Cover Bariatric Surgery?

Medicare may cover specific bariatric surgeries, like gastric sleeve / sleeve gastrectomy, gastric bypass, duodenal switch, and gastric banding (though this is rarely performed anymore). However, to qualify, you must meet certain conditions related to morbid obesity and its associated diseases.

Also note that while Medicare covers surgical expenses, it does not cover transportation to the medical facilities and may not cover gastric balloons, SADI, and mini gastric bypasses.

What Parts of Medicare Might Apply?

Medicare is split into several parts—A, B, C (Advantage), and D. Typically, bariatric surgery coverage falls under Medicare Part B (medical insurance) or Part A (hospital insurance), depending on the specifics of your hospital stay or if your procedure is being performed outpatient.

Medicare Part A
Medicare Part A covers inpatient hospital services if your surgery requires staying in the hospital (which most bariatric surgery does).

Medicare Part B
Medicare Part B can cover medical procedures performed in outpatient settings like certain parts of your pre-and post-operative care that happen outside of full hospital admission.

Requirements for Medicare Coverage for Bariatric Surgery
Medicare doesn’t just say, “Sure, go ahead!” for every weight loss surgery request. They’ll want to see that the bariatric surgery is medically necessary.

For Medicare to cover bariatric surgery, specific criteria might be required to be met, such as:

• Body Mass Index (BMI): Typically, a BMI of 35 or higher with obesity-related health conditions like:
• • Type II diabetes
  • Hypertension (high blood pressure)
  • Hyperlipidemia
  • Obesity-induced cardiomyopathy
  • Obstructive sleep apnea
  • Obesity-related hypoventilation
  • Pseudotumor cerebri
  • Severe joint disease of the spine and/or weight-bearing joints
  • Hepatic steatosis (non-alcohol fatty liver)
• Provide Evidence: Many times, Medicare asks for proof that you have made several attempts to lose weight, such as diets, prescription medications, and exercise programs. Despite using such methods, you have failed to lose weight. You’ll need to provide medical records or other proof showcasing your efforts.

A conversation with your bariatric surgeon’s office will help you understand what to expect and which procedures are typically approved under Medicare guidelines, so you’ll have a general idea of your expenses going forward.

The Medicare Approval Process for Bariatric Surgery

If you meet the criteria for Medicare coverage for bariatric surgery, you’ll usually need to follow specific steps to ensure that coverage becomes a reality:

Who Can Perform These Surgeries:

Only Medical Physicians (MD or DO) certified or eligible for certification by the American Board of Surgery, American Osteopathic Board of (General) Surgery, and/or a Fellow of the American or Royal College of Surgeons or Regular Member of the American Society of Metabolic and Bariatric Surgery can perform bariatric procedures and be covered.

Pre-Authorization
Medicare does not provide pre-authorization, so be sure to coordinate your claim with your bariatric practice. While Medicare does not provide pre-authorization for surgery, they still have requirements including: four months of weight loss visits, a psych evaluation, and a dietary consultation in advance of your procedure.

Waiting Periods
While there is no defined approval period, Medicare wants to ensure you have exhausted all reasonable options to lose weight before surgery. Depending on your case, you may be required to pursue a supervised diet or show consistent weight loss attempts for a few months before surgery.

Confirmation
Once the claim is submitted, Medicare will determine whether the procedure is covered and to what extent it will provide coverage. You’ll get an idea of how much of the cost you’ll be responsible for, if anything, after Medicare processes the claim.

Out-of-Pocket Costs
You may still have deductibles or coinsurance.

Medigap (Medicare Supplement)
Some of these costs might be partially or fully covered if you have a Medigap (Medicare Supplement) plan.

Medicare Advantage Plan (Part C)
You’ll have a specific cost structure if you’re on a Medicare Advantage plan (Part C). Reviewing your plan or calling your insurance provider to understand what part of the tab you’ll be expected to pick up is a good idea.

Helpful Tips on Handling Medicare for Bariatric Surgery

Let’s take a look at a few tips on how to handle Medicare for bariatric surgery:

• Talk to Your Surgeon’s Office: You’ll have questions about the Medicare or bariatric surgery process. Ideally, you should contact your surgeon’s office to discuss these. They’ve worked with Medicare many times before. Their insurance coordinators will help you handle the paperwork and can give you insight into the process.
• Stay Organized: Keep copies of all documents—doctor’s letters, diet plans, test results—so you can quickly provide proof of your weight loss journey if Medicare requests it.
• Don’t Skip Follow-Up Care: Medicare also covers follow-up visits and nutritional counseling, so take advantage of that to boost your success after surgery. It is very important to keep all appointments with your primary doctor as well. Skipping a month can make many insurance providers (if not all of them) start the whole process again.

Having Medicare shouldn’t discourage you from considering bariatric surgery. In fact, having Medicare can prove beneficial because it gives you coverage options that help you save money and receive the surgery you need. While there are some requirements to fulfill when reaching out to Medicare for bariatric surgery, many patients find reducing long-term health risks and improving their quality of life worthwhile. With some planning and the proper support from your healthcare team, you can easily handle Medicare’s coverage process for bariatric surgery.

Ready to take the next step? Contact a bariatric specialist to see if Medicare covers your surgery.