Weight loss surgery — also known as bariatric surgery — may provide a solution for some people struggling with the impact of obesity.
Medicare covers three types of bariatric surgery for patients that meet the requirements for coverage in terms of Body Mass Index, complicating conditions (known as comorbidities) and history with other weight-loss methods.
Part A of Original Medicare covers hospital-related expenses; Part B covers medically necessary treatments, services, and equipment; Part D covers drugs not covered by Parts A or B.
All Medicare parts require that you cover some of the associated costs, premiums, deductibles and coinsurance.
Medicare Advantage can replace Original Medicare while offering at least the same coverage as Parts A and B along with additional coverage options.
Obesity has become a national health epidemic, one that the field of bariatric medicine is committed to curbing.
Does Medicare cover bariatric surgery? Yes, in some instances.
The National Health and Nutrition Examination Survey found that from 2017-18, 42.8 percent of Americans age 60 and older were obese; 5.8 percent were severely obese. Body Mass Index (BMI) considers people with a score of 30 or more as obese, while severe obesity is a BMI of 40 or more.
Medicare approves several surgical procedures for weight loss for people with a BMI of 35 or more.
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Surgery that helps reduce caloric intake and absorption has become a popular and effective treatment for people who haven’t had success with less invasive treatments. Surgical approaches continue to develop, and at this time, Medicare covers three types of surgery for eligible patients.
Does Medicare cover gastric bypass surgery, the oldest form of weight loss surgery? It does, in addition to a couple of newer procedures.
Roux-en-Y gastric bypass (open or laparoscopic) is a type of gastric bypass surgery more than a half-century old. The procedure creates a smaller stomach and a smaller path through the small intestine, leading to decreased hunger and food absorption.
Biliopancreatic Diversion with Duodenal Switch or Gastric Reduction Duodenal Switch (open or laparoscopic): is the most effective surgical weight loss approach for diabetes patients. The procedures work similarly to gastric bypass but remove large portions of the stomach rather than just bypassing it and may also remove most of the duodenum (the first portion of the small intestine).
Adjustable gastric banding (laparoscopic): The least invasive of the Medicare-approved procedures, sometimes used with less severe patients, places a silicone band around the top portion of the stomach that limits hunger and consumption.
(Note: “Open” procedures feature one large incision; “laparoscopic” procedures feature several tiny, targeted incisions.)
The Centers for Medicare & Medicaid Services (CMS) Medicare Coverage Database outlines approved procedures. Approved bariatric procedures are covered for beneficiaries that,
- Have a body-mass index of more than 35
- Have at least one co-morbidity related to obesity
- Have been unsuccessful with medical treatment for obesity.
A co-morbidity is the presence of a condition concurrent with the primary disease. Examples of co-morbidities that pair with obesity include diabetes, high blood pressure and sleep apnea.
Medicare qualification for weight loss surgery actually will be determined on a case-by-case basis, meaning that the answer to the question, “Does Medicare cover weight loss surgery?” doesn’t always have a black-and-white answer despite the guidelines offered by CMS.
That means there’s a possibility that someone with a 35-plus BMI, a co-morbidity, and a previous failed attempt with medical treatment for obesity still won’t be covered by Medicare. Still, that determination should be made before surgery if at all possible to avoid unexpected costs.
For example, a laparoscopic sleeve gastrectomy may not be approved nationally but may be available locally. According to Medicare, local Medicare administrative contractors can approve a laparoscopic sleeve gastrectomy on a case-by-case basis.
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A 2017 study posted on the National Institutes of Health website put the average bariatric surgery cost (in 2016 dollars) at around $14,000 but with a standard deviation of more than $5,000.
Weight loss surgery costs will vary based on various factors, but if Medicare approves the procedure, you will pay some, but a relatively small portion, of the typical weight loss surgery cost.
Most people receive bariatric surgery on an inpatient basis, but outpatient weight loss surgery is more common each year.
- Of the nationally approved Medicare procedures, laparoscopic adjustable gastric banding is the least invasive and the most likely to be performed on an outpatient basis.
- Biliopancreatic Diversion with Duodenal Switch/Gastric Reduction Duodenal Switch are the most invasive and the most likely to be performed on an inpatient basis.
- Roux-en-Y gastric bypass may be outpatient in a few instances but more often remains inpatient.
Why does inpatient versus outpatient matter?
For the patient, an outpatient procedure indicates that recovery might be more manageable. And for practical purposes, it will help determine how and what Medicare pays for the procedure. Interestingly, based on an average cost, a patient on Original Medicare may pay less out of pocket for an inpatient procedure.
- Part A of Original Medicare, known as hospital insurance, covers inpatient surgery. Patients are typically responsible for the benefit period deductible but only have to pay coinsurance if the hospital stay tops 60 days. There may be some Part B cost responsibilities as well.
- Part B of Original Medicare, known as medical insurance, covers outpatient surgery. With Part B, patients typically are responsible for 20% coinsurance after paying their annual deductible, while Medicare pays 80% of the costs. Expenses incurred after the surgery, in most cases, will fall under Part B as well.
Parts A and B qualify you to add a Part D drug plan to help with related prescription costs.
Alternatively, having Parts A and B allows you to switch to Part C (Medicare Advantage). Your costs may be different with Medicare Advantage. However, your plan will provide at least the same coverages as Parts A and B. Medicare Advantage plans from private insurance companies replace Parts A and B. It may provide additional coverage related to bariatric surgery, including drug costs. Costs will vary from one plan to another, but all Medicare Advantage plans feature an out-of-pocket maximum for the plan year.
Medicare technically doesn’t put a time frame on approval for weight loss surgery. Medicare, like other health insurance entities, expects due diligence before approving surgery.
A still-recognized 2006 CMS decision memo states:
“The standard of care for any surgical procedure is that medical management options are exhaustively considered and exercised by both patient and physician before surgery. This standard applies to the treatment of co-morbid conditions related to obesity. We will not impose a specific period, but expect all surgeons to be part of a comprehensive program for the treatment of co-morbid conditions related to obesity and to have applied principles of good medical care before surgery.”
What is the wait time for bariatric surgery using Medicare?
There is no set time for Medicare to approve weight loss surgery, but it’s a surgery that your doctor or Medicare doesn’t enter into lightly.
Facilities that perform bariatric surgery have real-world experience working with Medicare and other insurances and know what it takes to get approval for weight loss surgery.
So even though Medicare states that the only pre-surgery requirements are:
- A BMI of 35 or more
- At least one co-morbidity related to obesity
- An unsuccessful medical treatment for obesity
For example, North Carolina Surgery (UNC Health Care surgical centers) tells Medicare beneficiaries, “Patient will be required to be seen monthly for six consecutive months. Medicare will require you to start the program over if a monthly appointment is missed.” And the University of Pittsburgh Medical Center states, without mentioning Medicare specifically, that bariatric patients must take “Six (monthly) bariatric pre-surgical lifestyle classes to fulfill insurance requirements.”
So while Medicare doesn’t explicitly have a waiting period for bariatric surgery, facilities that work with Medicare can provide some perspective.
What extra benefits and savings do you qualify for?
Medicare doesn’t cover cosmetic surgery, but it may cover cosmetic procedures if they are medically necessary for a particular situation.
Medicare lists a panniculectomy, defined as “surgery to remove excess skin and tissue from the lower abdomen,” among a list of outpatient services that may be covered “because of accidental injury or to improve the function of a malformed body part.”
As with bariatric surgery and other surgical procedures, you should work with your healthcare provider to determine if Medicare will cover the procedure.