Does Medicare pay for Bariatric Surgery?

Medicare has been covering bariatric surgery for beneficiaries since 2005. However, patients must meet pre-approval requirements. They must prove the procedure is a medical necessity. Medicare only covers certain types of weight-loss surgeries, such as gastric bypass, lap-band, duodenal switch, and gastric sleeve.

Medicare is a national social insurance program available for U.S. citizens. It guarantees access to health insurance for individuals over 65 and for younger people with disabilities. Medicare Part A covers hospital care while Part B outpatient services. The Medicare Advantage plan, Part C, is a program where the federal government pays for private health coverage. Medicare Part D covers outpatient prescription drugs. On average, Medicare covers about 50% of the medical costs of the insured individual.

In order to qualify for Medicare insurance coverage, patients must meet the following criteria:

  • Have Medicare insurance
  • Have a body mass index (BMI) of at least 35
  • Have at least one obesity-related medical condition
  • Have documented obesity for at least 5 years
  • Have a documented evidence of failures to lose weight with other methods
  • Present a letter from their doctor recommending weight-loss surgery
  • Pass a psychological evaluation
  • Choose a procedure approved by Medicare

For patients covered under an original Medicare plan, the insurer will typically cover 80% of the approved amount. Medicare Advantage covers at least what the Original Medicare Plan covers, and it may cover more. With a Medicare Supplemental Plan, patients might pay little or nothing.

Medicare also covers:

  • Inpatient hospital stay including semiprivate room, food and tests
  • An initial assessment of your eating and activity habits
  • Counseling on diet and physical activity
  • Education on how to improve your diet
  • Follow-up visits to monitor your diet and weight loss progress

LAP-BAND, gastric bypass, and gastric sleeve procedures are covered by Medicare if your designated Medicare doctor decides that you meet certain criteria relevant to obesity. Medicare will cover the procedure if you:

  • Have a BMI (body mass index) equal to or greater than 35.
  • Have been previously unsuccessful in receiving medical treatment for obesity
  • Have at least one co-morbidity, or related condition, that is relevant to obesity. These may include diabetes, sleep apnea, and other conditions.

The average cost of lap-band surgery across the United States is $14.532, but with Medicare, the cost becomes much more manageable for the patient. For more information, visit our lap-band surgery cost page.

Medicare will not pay for the surgery unless it is performed at a Medicare-approved "Center of Excellence" for bariatric surgery. The Centers for Medicare & Medicaid Services website has a complete list of approved centers for bariatric surgery at www.cms.gov. You should also ask your health care provider to recommend a local center.

Once you have chosen your center, make sure to ask the surgeon whether they are participating providers, if they accept assignments, and what exactly the charges are and how much you will be responsible for out of pocket.

Disclaimer: We do not assume responsibility for the use of the provided information or its interpretation. Our efforts are towards providing current and reliable information; however these should not be considered, or used as a substitute for diagnosis or treatment.

Source: https://www.cedars-sinai.edu/Education/Medical-Library/

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