Medicare covers some, but not all, types of weight loss surgery if a person meets several conditions.
In order for Medicare to cover weight loss surgery, the person must have 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%. An individual must pay deductibles, coinsurance, and copayments. Total costs depend on several factors.
Below, we discuss weight loss 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.
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.
Weight loss surgery is an operation that makes changes in a person’s digestive system to help them lose weight. The surgery works in two main ways:
Firstly, it makes the stomach smaller. This surgical change helps someone feel fuller more quickly after eating and drinking, which reduces the amount of food that they can eat at one time.
Secondly, it changes the small intestine. The small intestine is a part of the body that absorbs nutrients and calories from beverages and food. Procedures that divert food away from the small intestine will result in a lower absorption of calories.
Surgeons perform the procedures using one of two methods. The open method involves making a large cut in the abdomen, while the laparoscopic method consists of making several small cuts in the abdomen and inserting tiny surgical tools through the cuts.
None of the surgeries can guarantee a specific amount of weight loss.
However, studies show that the average person who has one of the procedures loses 15–30% of their starting weight. People may not always lose as much weight as they desire, and some people gain back some of the weight that they lose.
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. Two of them work by both making the stomach size smaller and changing the small intestine. The third option deals solely with making the stomach smaller.
The procedures are:
Open and laparoscopic Roux-en-Y gastric bypass
This surgery involves stapling the stomach, which greatly reduces its size. It also includes cutting part of the small intestine and attaching it to the stomach. 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.
As evidence is insufficient to show that some weight loss procedures are reasonable and necessary, Medical does not cover them. These include the surgeries below, some of which have caused safety concerns:
- Open and laparoscopic vertical banded gastroplasty, which is the combination of stapling and the insertion of a band to create a very small stomach.
- Open and laparoscopic sleeve gastrectomy, which is the removal of most of the stomach.
- Open adjustable gastric banding, which is similar to the laparoscopic version, except that surgeons perform it through a large cut in the abdomen.
- Gastric balloon surgery, which is the insertion of a device into the stomach to reduce its capacity.
- Intestinal bypass, which is surgery that bypasses much of the small intestine.
According to the National Institute of Diabetes and Digestive and Kidney Diseases, weight loss surgeries cost between $15,000 and $25,000.
It is difficult to estimate the portion of this amount that a person must pay, as it is not possible to determine the necessary services in advance. Original Medicare provides coverage for those who meet the eligibility requirements, but deductibles, coinsurance, and copayments apply.
Total expenses depend on the type of surgery, among 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 with original Medicare may expect the following costs:
If someone with original Medicare has a Medigap plan, which is Medicare supplement insurance, it will 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 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: through Part D, which is prescription drug coverage available to anyone with original Medicare, or through Medicare Advantage instead of original Medicare, if the plan includes prescription coverage.
Certain side effects may happen immediately after the surgery, while others may occur later. Immediate side effects may include:
- leaking from the surgical site
- blood clots in the legs that can travel to the heart or lungs
Surgery-related problems rarely lead to death, but this is always a possibility.
The following side effects may occur later:
- A person may not be able to absorb nutrients well, which may lead to health conditions such as anemia and osteoporosis.
- Rapid weight loss may result in gallstones.
- An individual may experience strictures, a narrowing of the stomach or intestinal tissue that can cause vomiting, nausea, and trouble with swallowing.
- Bypass surgery may change the way the body absorbs alcohol, which can lead to alcohol-related problems.
Medicare covers certain weight loss surgeries if a person meets several conditions. However, someone undergoing the surgery is responsible for deductibles, copayments, and coinsurance.
Weight loss surgeries that Medicare covers reduce the stomach size, redirect food from the small intestine, or both. The procedures come with side effects and risks, some of which are serious.
People who are considering one of the surgeries may wish to discuss the potential benefits and risks with their doctor.
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