Medicare covers some, but not all, types of weight loss surgery if a person meets the criteria.
Medicare will only cover weight loss surgery if the person has a body mass index (BMI) associated with a significant degree of obesity. In addition, they must have a history of unsuccessful obesity treatment, as well as at least one illness relating to the condition.
The coverage is not 100%, and an individual must pay deductibles, coinsurance, and copayments. The total costs will depend on several factors.
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.
Below, we discuss weight loss surgery, also known as bariatric surgery, and then look at Medicare’s eligibility requirements. We also explain the types of procedures that Medicare covers, the costs involved, and the risks of the surgery.
Medicare has ruled that some weight loss procedures are reasonable and medically necessary for people who meet these criteria:
- They have a BMI of 35 or higher.
- They have had previous unsuccessful obesity treatment.
- They have at least one of the illnesses associated with obesity. These include high blood pressure, high cholesterol, type 2 diabetes, sleep apnea, heart disease, stroke, osteoarthritis, respiratory problems, gallbladder disease, and certain types of cancer.
Medicare covers three different procedures, all of which make the stomach smaller. Two of the procedures also change the small intestine.
The procedures are:
- Open and laparoscopic Roux-en-Y gastric bypass: This surgery involves stapling the stomach to create a pouch, which greatly reduces its size, and connecting it to part of the small intestine. This two-part procedure results in a person eating and absorbing less food.
- Open and laparoscopic biliopancreatic diversion with duodenal switch: This option consists of two separate surgeries. The first procedure cuts out part of the stomach, while the second redirects food to bypass the greater part of the small intestine. This procedure results in more weight loss, but it also has a higher risk of surgery-related problems and nutrient deficiencies.
- Laparoscopic adjustable gastric banding: This surgery involves placing a band around the upper portion of the stomach, which creates a small stomach pouch. The band has a balloon inside containing salt solution. A surgeon can adjust the size of the pouch by either removing or injecting a solution through a port that sits under a person’s skin.
Medical does not cover weight loss procedures for which there is insufficient evidence to confirm that they are reasonable and necessary. These include the surgeries below, some of which have caused safety concerns:
- Open and laparoscopic vertical banded gastroplasty: This combination of stapling the stomach and inserting a band creates a very small stomach.
- Open and laparoscopic sleeve gastrectomy: This procedure involves the removal of most of the stomach.
- Open adjustable gastric banding: This procedure is similar to the laparoscopic version, except that surgeons perform it through a large cut in the abdomen.
- Gastric balloon surgery: Surgeons insert a device into the stomach to reduce its capacity.
- Intestinal bypass: This surgery bypasses much of the small intestine.
According to the National Institute of Diabetes and Digestive and Kidney Diseases, the cost of weight loss surgery is in the range of
It is difficult to estimate the portion of this amount that a person must pay out of pocket, as it is not possible to determine the necessary services in advance. Original Medicare, which comprises Part A and Part B, provides coverage for those who meet the eligibility requirements, but deductibles, coinsurance, and copayments still apply.
The total expenses will depend on the type of surgery and several other factors, including:
- whether an individual has met their deductibles
- whether a person has surgery-related problems
- if procedures take place on an inpatient or outpatient basis
A person can check whether they have met their deductible by accessing their Medicare portal or referring to their latest Medicare Summary Notice, which they should receive every 3 months.
In general, a person with original Medicare may expect the following costs in 2021:
If someone with original Medicare has a Medigap plan, which is Medicare supplement insurance, this plan may pay some or all of the uncovered expenses.
The costs for a person with Medicare Advantage are even more difficult to estimate because the deductibles, copayments, and coinsurance all vary with each plan. An individual may also need to choose from in-network providers.
If a doctor gives someone who has undergone the surgery a prescription for a medication, Medicare can help in two ways. The first is through Part D, which is prescription drug coverage available to anyone with original Medicare. The second is through Medicare Advantage — an alternative to original Medicare — if the plan includes prescription coverage.
Medicare covers certain weight loss surgeries if a person meets several conditions. However, the individual undergoing the surgery is responsible for deductibles, copayments, and coinsurance.
The weight loss surgeries that Medicare covers work by reducing the stomach size, redirecting food from the small intestine, or both.