Medicare Coverage for Weight Loss Surgery
There are certain medical criteria that must first be met before Medicare will even consider approving the surgical procedure.
The BMI must be higher than 35 in addition to having one other comorbidity. Comorbidity is when two or more chronic health issues are combined.
For example, obesity combined with high blood pressure, heart disease, sleep apnea, high cholesterol or diabetes, would be considered comorbidity.
Medicare Requirements for Bariatric Surgery
Medicare then requires documented medical records in which the individual has suffered from obesity for at least 5 years.
You also need documented proof of failing a medically supervised weight loss program.
There must be proof of medical necessity from your healthcare provider.
As well as a psychological evaluation clearing you for surgery.
And lastly, additional labs testing that the thyroid, pituitary, and adrenal levels are within normal range and, therefore, not causing the weight gain.
Once the necessities have been met then Medicare will provide coverage for bariatric surgery.
Medicare Covered Weight-Loss Surgeries
There are various experimental weight loss procedures that Medicare doesn’t cover, however, Gastric Bypass, Lap-Band, Duodenal Switch, and a Sleeve Gastrectomy are all covered.
Depending on if the bariatric surgery is performed at a hospital or an outpatient facility will depend on which Medicare Plan will provide coverage.
Any inpatient surgery and services, while hospitalized, will be covered by Part A.
Any outpatient surgery and surgical aftercare with your physician will be covered by Part B.
Once your deductibles have been met, both Part A and Part B provide 80% coverage. This leaves the remaining 20% for the Medicare beneficiary to pay.
Depending on the length of stay in the hospital and how frequent your follow up visits are with your healthcare provider, will determine yours out of pocket costs.
Medicare Approved Bariatric Surgeries
With bariatric surgery becoming increasingly popular for weight loss, here are the Medicare-approved surgeries:
- Gastric Bypass
- Gastric Sleeve Surgery
- Lap Band Surgery
- Duodenal Switch Surgery
Does Medicare Cover Gastric Bypass
Yes, as long as you follow along with the requirements above, Medicare will cover Gastric Bypass surgery.
Gastric Bypass is the most common and been around the longest, popular since the 1960s.
With Gastric Bypass surgery the original stomach is divided and a “new”, stomach is formed, much smaller. When you have a smaller stomach, less food is needed. With fewer calories comes weight loss.
Does Medicare Cover Gastric Sleeve Surgery
Yes, Medicare will cover Gastric Sleeve surgery. Gastric Sleeve Surgery uses a stapling device to shrink the stomach, causing a “sleeve.” The remainder of the stomach, up to 85%, is then removed, therefore, making this a permanent procedure.
Does Medicare Cover Lap Band Surgery
Yes, Medicare will cover lap band surgery. The cost will depend on many factors, its best to ask your doctor how much it will cost to get an idea of your out of pocket costs.
Lap Band Surgery uses an adjustable band around the stomach that can be inflated using saline (sterile water). The band is adjusted according to the individual’s weight-loss progression. The procedure itself is easier than the others as it’s done laparoscopically. Additionally, it has an easier recovery and can be reversed if necessary.
Does Medicare Cover Duodenal Switch Surgery
Yes, Medicare will cover Duodenal Switch surgery. Duodenal Switch Surgery reduces the stomach by doing a sleeve gastrectomy and intestinal bypass. The surgeon removes up to 70% of the stomach and then 2/3’s of the intestine is bypassed.
This leaves only a small amount of intestine where the food and digestive enzymes meet. The reduction in the size of both the stomach and small intestine decreases the amount of caloric intake the body absorbs.
With any surgical procedure, there are risks and benefits that should be discussed with your healthcare provider.
While bariatric surgery is common and ultimately has good success rates, consider all options and do your research prior to proceeding.
On the positive, bariatric surgery has a high success rate of achieving long-term weight-loss as well as improving the overall quality of health.
How Long Does it Take Medicare to Approve Bariatric Surgery
This time frame can be different for each person, but on average it can take 3-4 months to get Medicare to approve bariatric surgery.
Gastric Bypass Revision Surgery, Is It Covered by Medicare
A revision request from a prior failed surgery will trigger lots of questions, so make sure you and your doctor are on the same page.
If Medicare finds that your request is medically necessary, then they will cover the cost of the revision surgery.
There’s a great article written by Gary Viscio that discusses how to prepare for this type of revision request.
39.6% of American are Impacted by Obesity
With the obesity rates in the United States rapidly rising, Americans are actively looking for ways to treat this condition that affects 39.6% of us all.
Of the 39.6%, obesity in women is only just slightly higher than men. Morbid obesity is considered weight greater than 100 pounds over what medical practitioners consider ideal and healthy for an individual’s height.
Additionally, the doctor’s measure a patient’s body mass index (BMI) as a way to evaluate your body fat and also determine if you’re considered overweight.
They use your weight in pounds and height in inches, squared, and then divided by a specific number to determine what a person’s current BMI is. A BMI score of anything greater than 25 is considered overweight.
Those individuals with an elevated BMI or, “overweight”, are at a higher risk for cardiac disease, diabetes, hypertension (high blood pressure), strokes, cancer, gallbladder disease and in the worst-case scenario, even death.
So, what can be done to prevent any major health issues associated with adult obesity? Other than diet and exercise, some adults consider bariatric surgery.
With changing the anatomy of the GI tract, the intestinal hormones that normally produce appetite sensations or hunger, are reversed.
Once reversed, the individual ends up feeling less hungry and, therefore, takes in fewer calories and they lose weight.
How to Get Additional Help for Bariatric Surgery
As most surgeries require multiple overnight stays in the hospital, as well as numerous, follow-ups with your physician, the cost can quickly add up.
With Medicare only covering 80%, seniors on a fixed income may feel like bariatric surgery is at an unattainable reach. There is good news though seniors!
There are supplemental insurance plans offered by private insurance carriers that can provide extra insurance coverage.
This includes coverage for things such as deductibles, coinsurance, and copayments. Depending on your individual healthcare requirements will depend on which package can best suit your needs.
Fill out our online rate form for more information on the Medicare Supplement Plans available to you in your area. There’s no obligation to purchase and our agents can answer any insurance plan questions you have.