Does Medicare Cover Bariatric Surgery?

Medicare covers bariatric surgery for beneficiaries diagnosed with morbid obesity. Weight loss surgery is considered when a person’s obesity has been detrimental to their health, and all other forms of weight management have been ineffective.

What Is Bariatric Surgery?

Bariatric surgery is a medical procedure that makes changes to a person’s digestive system to facilitate weight loss. Bariatric surgery is considered if dietary changes and exercise were ineffective for weight loss and the weight is causing significant health problems. Types of bariatric surgeries include:¹Mayoclinic.org, “Bariatric surgery“, Accessed October 29, 2021

• Gastric Bypass Surgery
• Laparoscopic Banding (Lap-Band Surgery) or Realize Band Surgery
• Duodenal Switch
• Sleeve Gastrectomy

All weight-loss surgeries are major procedures that carry significant risks to the recipient. A full lifestyle change must be made to the person’s dietary and activity habits after surgery to enable the positive effects of the procedure.¹Mayoclinic.org, “Bariatric surgery“, Accessed October 29, 2021

How Does Medicare Cover Bariatric Surgery?

Medicare covers bariatric surgeries if the beneficiary meets the following eligibility conditions for morbid obesity:

• BMI (body mass index) of 35 or greater.
• At least one co-morbidity – a serious illness directly related to their obesity, such as:
  • High blood pressure
  • Hypertension
  • Type 2 diabetes
  • Sleep apnea
• Documented evidence that the beneficiary has been obese for the last 5 years.
• Documented participation in a medically supervised weight loss program.
• A letter from the beneficiary’s physician recommending or supporting a weight loss procedure.
• Passed a psychological evaluation.
• All other treatable medical conditions have been ruled out as a possible cause of obesity.

Bariatric surgeries are a major invasive surgical procedure, so the beneficiary will likely be admitted to an inpatient hospital covered by Medicare Part A. The beneficiary may instead receive bariatric surgery in a hospital outpatient department, which would be covered by Medicare Part B.²Medicare.gov, “Bariatric surgery“, Accessed October 29, 2021

How Much Does Bariatric Surgery Cost?

The cost of the bariatric surgery will depend on the area and what type of bariatric surgery is being done. According to the National Library of Medicine, the costs of bariatric surgery can range from $7,423 to $33,541, averaging at $14,389.³ncbi.nlm.nih.gov, “What Are the Real Procedural Costs of Bariatric Surgery? A Systematic Literature Review of Published Cost Analyses“, Accessed November 8, 2021

Increasingly, bariatric surgery is an outpatient procedure that’s covered completely by Medicare Part B. The dominant procedure performed in outpatient surgical centers is the laparoscopic adjustable gastric band (LAGB) procedure, which helps reduce the cost. Medicare covers 80 percent of all approved costs once the beneficiary has paid their annual Part B deductible. If the surgeon, anesthesiologist, or the surgical center charge Part B Excess Charges, the beneficiary is responsible for these costs.

When a bariatric surgery procedure is performed as an inpatient procedure the hospital costs are covered by Medicare Part A, which has a benefit period deductible. However, physician services for non-hospital employees, which generally includes the surgeon and the anesthesiologist, are covered under Part B.  Hospital services related to inpatient surgery include things like daily room and board, laboratory services, diagnostic tests, surgical equipment and supplies, anesthesia, and the services of nurses, and other health professionals.

Medicare Advantage

Medicare Advantage plans are required to cover the same services as Medicare Part A and Part B, in addition to any expanded services offered. That includes bariatric surgery. However, a beneficiary’s out-of-pocket costs with a Medicare Advantage plan may be different than those with Original Medicare. Also, Medicare Advantage plan rules may require their members to use network providers for all services, supplies, and durable medical equipment.⁴Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed October 29, 2021

Medigap

People with Original Medicare can purchase additional insurance, called Medigap, to help cover their Medicare out-of-pocket costs.  Medicare Supplement Insurance, as it is also known, is available through private insurance companies. Depending on the plan, a Medigap policy will cover some or all of the out-of-pocket costs associated with Medicare-approved bariatric surgery procedures. These costs include:⁵Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed October 29, 2021

• Deductibles
• Coinsurance
• Copayments
• Blood

Post-Surgery Medication Costs

When post-surgery medication is required it will generally be covered by a beneficiary’s Medicare Part D plan. Depending on the Part D plan, members may pay an annual deductible, before the plan begins paying its share, as well as a copayment.⁶Medicare.gov, “What Medicare Part D drug plans cover“, Accessed November 8, 2021

Summary

If you have been diagnosed with morbid obesity and other forms of weight management have been ineffective, consult with your doctor. Bariatric surgery could be the logical next step. If you meet the eligibility conditions, and your doctor orders the procedure, Medicare will pay its share.

Citations

• 1
  Mayoclinic.org, “Bariatric surgery“, Accessed October 29, 2021
• 2
  Medicare.gov, “Bariatric surgery“, Accessed October 29, 2021
• 3
  ncbi.nlm.nih.gov, “What Are the Real Procedural Costs of Bariatric Surgery? A Systematic Literature Review of Published Cost Analyses“, Accessed November 8, 2021
• 4
  Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed October 29, 2021
• 5
  Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed October 29, 2021
• 6
  Medicare.gov, “What Medicare Part D drug plans cover“, Accessed November 8, 2021