Original Medicare, Medicare Advantage, and Medigap may all provide coverage for gastric bypass surgery for people who meet certain criteria.
According to the American Society for Metabolic and Bariatric Surgery, in 2018, more than 250,000 people in the United States had bariatric surgery (also known as weight loss surgery). There are several types of bariatric surgery, including gastric bypass.
This article will look at Medicare coverage and eligibility for gastric bypass surgery. It will then discuss bariatric surgery, the two main types of gastric bypass surgery, some risks and benefits, and associated costs.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare covers bariatric surgical procedures, including gastric bypass surgery, when a person has certain obesity-related conditions.
Original Medicare covers the cost of approved gastric bypass surgeries. After the deductible, Part A covers inpatient gastric bypass surgeries that healthcare professionals perform in hospitals at 100%, while Part B covers outpatient gastric bypass surgeries at 80%.
Medicare Advantage may also cover gastric bypass surgeries. However, a person will need to check that their hospital or medical facility is within their insurer’s network.
People with Medigap plans may be able to get help with costs not covered by their standard Medicare plan.
In addition, a person could check with their employer to find out if their work insurance covers the surgery. Coverage might also be available through a family member who has a work insurance plan.
Medicare covers gastric bypass surgery for people who meet certain criteria, including:
- having a body mass index (BMI) greater than 35
- having at least one obesity-related comorbidity
- having tried other, unsuccessful medical treatments for obesity
A person with an obesity-related condition may also qualify for Medicare-subsidized gastric bypass surgery. Such conditions include:
- gallbladder disease
- heart disease
- high cholesterol
- high blood pressure
- sleep apnea
- some types of cancer
- type 2 diabetes
Medicare requirements can vary by state and individual insurance providers. However, people must usually provide the following information:
- the results of thyroid, adrenal, and pituitary blood tests showing all results in the normal range
- the results of a psychological evaluation
- proof of participation in at least one unsuccessful weight loss program that a medical expert supervised
- a doctor’s referral for gastric bypass surgery
Gastric bypass surgery is a type of bariatric surgery that reduces the size and capacity of a person’s stomach. Because the stomach holds less food after this surgery, a person will absorb fewer calories and fat.
There are several types of bariatric surgery, including:
- biliopancreatic diversion-duodenal switch
- gastric sleeve surgery
- laparoscopic adjustable band
- mini gastric bypass (MGB)
- Roux-en-Y gastric bypass (RYGB)
The two main types of gastric bypass surgery are RYGB and MGB.
RYGB is a common type of gastric bypass surgery. A surgeon will create a new, smaller stomach section. They will then join the smaller stomach part, called a pouch, to a part of the small intestine.
Having a smaller stomach, which can hold 1 ounce (30 milliliters), means that a person will feel fuller after eating a small amount of food and will consume fewer calories and fat.
Experts developed the MGB in 1997. A surgeon will usually carry out the operation using laparoscopic surgery, or keyhole surgery, and create a smaller stomach section. They will then join that section to a loop of the small intestine.
People considering gastric bypass surgery should carefully review all the possible risks and benefits to decide whether or not surgery is the right choice for them.
People should consider all the possible risks before undergoing gastric bypass surgery.
Potential complications may include:
- stomal stenosis, which is a tightening and narrowing of the opening between the stomach and small intestine
- dumping syndrome, wherein the stomach does not digest solid food before it reaches the small intestine
- peritonitis, which refers to inflammation of the lining of the abdomen due to a stomach leak
People considering gastric bypass surgery should ask their doctor for advice about their choice. The doctor can also suggest ways to lower the risks associated with surgery and treat any problems that may arise.
For example, if a person works with a nutritionist, they may be less likely to experience malnutrition. Taking supplements might also help a person prevent vitamin deficiencies, while making certain dietary changes can help ease dumping syndrome.
Stomal stenosis and peritonitis are also treatable with medical intervention. A person should monitor their health and tell their doctor about any post-surgery symptoms, as early detection may quickly resolve them.
Gastric bypass surgery has several potential benefits, including:
- long-term weight loss
- a greater life expectancy
- reduced appetite
- improved or resolved weight-related conditions, including high blood pressure, heart disease, and type 2 diabetes
- improved mobility
- improved mental health
- improved sexual function
- less reliance on medications
The cost of gastric bypass surgery varies by location and service. A person can check with their doctor or hospital for an estimate of the total cost, which can range from $7,423 to $33,541.
Out-of-pocket costs for gastric bypass surgery may also vary, depending on several factors. These include:
- how much a hospital or medical facility charges
- a person’s Medicare coverage
- whether or not the person has any other insurance
Whether a person is an inpatient or outpatient for surgery can also affect the costs. A person can use this tool to check which parts of Medicare cover the different aspects of their surgery. This allows them to see what their out-of-pocket expenses may be.
The amount that Medicare Advantage plans cover will vary among providers. Generally, people with a Medicare Advantage plan will pay surgery and hospital inpatient stay copays.
A person can use this tool to find more information about a specific plan.
People with Medigap plans can use this coverage for some or all of the expenses associated with gastric bypass surgery.
Medicare may provide coverage for gastric bypass surgery. However, a person must meet certain criteria.
A doctor can explain the benefits, risks, and costs of gastric bypass surgery to help a person decide whether or not it is right for them.
Most hospitals and medical facilities provide estimates for the cost of gastric bypass surgery and any aftercare expenses.
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