Does Medicare Cover Weight Loss Surgery?
Key takeaways:
Bariatric surgery (or weight loss surgery) helps people with obesity achieve weight loss.
Medicare covers certain bariatric surgeries, such as laparoscopic banding surgery and gastric bypass, if you meet certain requirements.
To qualify for coverage, you must meet specific body mass index (BMI) criteria, typically having a BMI of 35 or higher. Out-of-pocket costs such as deductibles, copays, and coinsurance depend on whether the surgery is an inpatient or outpatient procedure.
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Sometimes, lifestyle changes aren’t enough for people who are considered obese. When diet and exercise alone don’t work, bariatric surgery can be an option. These procedures change the structure of the stomach and intestines to achieve weight loss.
Medicare will cover certain bariatric surgeries if a doctor says the procedure is medically necessary and you meet certain medical criteria. The best way to learn about covered surgeries, requirements, and costs is to check your plan. You can also talk to a Medicare representative.
What is bariatric surgery?
Bariatric surgery helps people achieve sustainable weight loss by altering the structure of the digestive system. It's also known as weight loss surgery. Bariatric surgery achieves weight loss through two methods: reducing the size of the stomach and bypassing the small intestine (where food is absorbed). Surgeries can involve one or both of these methods.
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Types of bariatric surgeries include the following:
Roux-en-Y gastric bypass (RYGB). This method reduces the size of the stomach and bypasses some of the small intestine. It can be done as a keyhole surgery (laparoscopic) or an open procedure.
Adjustable gastric banding (AGB). This is a keyhole surgery that reduces the size of the stomach by placing an inflatable band around it.
Biliopancreatic diversion with duodenal switch (BPD/DS) or gastric reduction duodenal switch (BPD/GRDS). These operations are similar to RYGB, in that they restrict stomach size and bypass the small intestine. They can be done as keyhole surgeries or open procedures.
Sleeve gastrectomy. This surgery removes some of the stomach and leaves a smaller stomach. It is similar to RYGB, except it doesn’t bypass part of the small intestine. Like RYGB, this procedure can be done as a keyhole surgery or an open surgery.
Some weight loss procedures are more common in the Medicare community than others. Laparoscopic (keyhole) sleeve gastrectomy (LSG) is on the rise. That's according to a 2020 study on Medicare bariatric surgeries. Laparoscopic Roux‐en‐Y gastric bypass (RYGB) is decreasing. Laparoscopic adjustable gastric banding (LAGB) is also on the decline.
Does Medicare cover weight loss surgery?
Medicare covers specific bariatric surgical procedures when a recipient meets the medical criteria. Their doctor must also insist the surgery is medically necessary.
Medicare covers the following bariatric surgeries as long as certain requirements are fulfilled:
Laparoscopic sleeve gastrectomy (LSG)
Laparoscopic adjustable gastric banding (LAGB)
Gastric reduction duodenal switch (BPD/GRDS)
Open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS)
Open and laparoscopic Roux-en-Y gastric bypass (RYGB)
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For stand-alone laparoscopic sleeve gastrectomy, Medicare Administrative Contractors (MACs) may assess coverage eligibility. MACs can process claims with certain geographic jurisdictions.
Medicare doesn’t cover the following weight loss procedures:
Open sleeve gastrectomy
Open adjustable gastric banding
Open and laparoscopic vertical banded gastroplasty
Gastric balloon
Intestinal bypass surgery
Without insurance, bariatric surgery costs range from $7,400 to $33,000. The total price depends on which operation you choose.
What are the requirements for Medicare weight loss surgery?
For Medicare bariatric surgeries, you must meet the following requirements for coverage:
You have a body-mass index (BMI) of 35 or higher.
You live with at least one medical complication related to obesity. Examples include hypertension, diabetes, dyslipidemia, or obstructive sleep apnea.
You have been previously unsuccessful with medical treatment for obesity.
You must also meet the following specifications:
You have had documented participation in a medically supervised weight loss program.
You have been evaluated by a bariatric surgeon who recommended surgical treatment.
You have undergone a separate medical evaluation from a physician other than a surgeon.
You have received mental health and psychosocial clearance for bariatric surgery by a mental health provider.
You have had a nutritional evaluation by a physician or registered dietitian.
It’s possible to meet these requirements and still discover that your chosen procedure is not listed at all. MACs can decide on coverage for bariatric surgeries that are not listed as covered or non-covered.
How to get coverage approved for Medicare weight loss surgery
The following four steps will increase your chances of getting Medicare to cover your weight loss surgery:
The first step of Medicare bariatric surgery approval is crucial: Your doctor must deem the procedure medically necessary.
Your next move is to check your Medicare plan for coverage requirements. Or you can contact a Medicare representative to review the criteria. Your healthcare provider may also help determine Medicare coverage and ensure payment.
If Medicare doesn’t cover your bariatric surgery, check other insurance that you may carry. Policies may include Medicare Supplement Insurance (Medigap) and Medicaid. Medicare Advantage coverage details vary. However, plans must cover the same benefits as Medicare. This mandate holds true even if the stipulations and out-of-pocket costs are different.
If you or your spouse are still working, check your employer-sponsored health insurance. It may cover bariatric surgery.
What are the out-of-pocket costs for Medicare weight loss surgery?
So you’ve met all the requirements for Medicare bariatric surgery coverage. Now, your share of the bill depends on whether you have an inpatient or outpatient procedure. You’ll want to review Medicare Part A if you’ll be admitted to the hospital. Check out Medicare Part B if you plan to have surgery and return home the same day. Note: Medicare doesn’t cover transportation costs for bariatric surgery.
Medicare weight loss surgery usually includes the following out-of-pocket costs:
Deductible: The deductible for Part A coverage in 2024 is $1,632 for each inpatient hospital benefit period. A benefit period starts the day you're admitted. It ends when you haven't spent the night in the hospital for 60 consecutive days. The deductible for Part B in 2024 is $240.
Coinsurance: For Part A in 2024, the first 60 days of a hospital stay for Medicare bariatric surgery don’t have any coinsurance. The cost begins on Day 61 ($408) and goes up on Day 91 ($816 per each lifetime reserve day). You pay all costs after your 60 lifetime reserve days are used. For Part B, your coinsurance is usually 20% of the Medicare-approved amount after you’ve met your deductible. So, if the surgery cost $10,000, you’d expect to pay $2,000.
When to talk to a healthcare provider about Medicare weight loss surgery
If you think you’re a Medicare bariatric surgery candidate, talk to your doctor. They can discuss your plan coverage, procedure options, and surgeon referrals.
During your first appointment with a weight loss surgery professional, they may cover the following steps:
Conduct an individual surgical consultation
Help you decide on the right procedure
Ensure that you have made nutrition and lifestyle changes
Make sure that you are prepared for any emotional, social, and psychological concerns
Discuss financial and insurance considerations
You may also go through a series of medical tests, such as:
Blood and urine tests
Chest X-ray
Ultrasound
The tests will check your health and help you and your healthcare providers choose the right surgery for you. They'll also discuss ways to reduce complication risks. Your weight loss surgery professional will then submit documentation to get your surgery approved.
The bottom line
Medicare covers specific bariatric surgeries. However, you must meet certain medical criteria. Plus, your doctor must say the procedure is medically necessary.
If Medicare covers your surgery, Part A will pay for an inpatient procedure. Part B will pay for outpatient surgery. This distinction will also determine your out-of-pocket expenses.
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References
Centers for Medicare & Medicaid Services. (n.d.). Bariatric surgery for treatment of co-morbid conditions related to morbid obesity.
Centers for Medicare & Medicaid Services. (n.d.). Billing and coding: Bariatric surgery coverage.
Centers for Medicare & Medicaid Services. (2023). What’s a MAC. Duke Health. (2021). Your first weight loss surgery appointment: What to expect.
Lim, Y., et al. (2023). Obesity and comorbid conditions. StatPearls.
Medicare.gov. (n.d.). Bariatric surgery.
Medicare.gov. (n.d.). Costs.
Penn Medicine. (n.d.). Bariatric surgery process: What to expect.
Wirth, K., et al. (2021). Bariatric surgery outcomes in Medicare beneficiaries. Obesity Science & Practice.
