What Medicare Covers for Bariatric Surgery

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This article was updated January 14, 2020. 

Bariatric surgery (also known as weight loss surgery) is used to treat obesity that causes additional health problems, and Medicare covers it for qualified beneficiaries. Your doctor will help you choose from the four types of weight loss surgery to decide which one is right for you and your health.

Types of bariatric surgery

There two different types of bariatric surgery based on how they help the patient lose weight:

  1. Restriction. This surgery limits the amount of food you can hold in your stomach at any given time. This can be accomplished by reducing the size of the stomach or removing part of it entirely. 
  2. Malabsorption. Malabsorption surgery limits caloric intake by rerouting part of the intestines to prohibit food absorption of both nutritional and non-nutritional calories. 

The four main bariatric surgery procedures are:

  1. Roux-en-Y gastric bypass (gastric bypass). This is the oldest weight loss surgery still used today. The surgeon creates a small pouch in the top of the stomach and connects the pouch to the beginning of the small intestine. Patients who have this surgery lose about 70 percent of excess weight following the procedure.
  2. Laparoscopic adjustable gastric banding (lap band). Like gastric bypass, this surgery limits the amount you can comfortably eat or drink. An inflatable balloon is placed around the upper part of the stomach, and a port is placed under the skin of the abdomen. The balloon can be inflated or deflated by injecting or removing saline through the port. After lap band surgery, Medicare also covers balloon maintenance, or fills.
  3. Sleeve gastrectomy (gastric sleeve). In this surgery, about 85 percent of the stomach is separated and removed. The remaining portion is formed into a tube-like shape which cannot hold much food or liquid. This surgery is the fastest growing weight loss surgery, and patients lose an average 65 percent of their excess weight following the procedure.
  4. Duodenal switch with biliopancreatic diversion (BPD/DS or duodenal switch). This relatively new surgery is more complicated with a risk of malnutrition and vitamin deficiency, but it’s also very effective. The surgeon removes a large portion of the stomach and then attaches it to the beginning of the small intestine (duodenum). This is recommended for patients with a BMI of 50 or more. Patients with this procedure lose an average 75 percent of their excess weight.

Medicare coverage

To determine if you qualify for bariatric surgery, Medicare Part B will cover an obesity screening. Your body mass index (BMI) will need to be at least 35 in order to qualify. If you have a Medicare Advantage plan, the BMI threshold may differ. 

Qualifying for weight loss surgery

In order to qualify for weight loss surgery, you must:

  • Have two or more instances of co-morbidity (a serious illness, like high blood pressure, diabetes, and sleep apnea)
  • Have been obese for the past five years
  • Have a BMI of 35 or higher
  • Show that you have enrolled in a medically supervised weight loss program and that you have failed at least one in the past
  • Provide Medicare with a letter from your doctor recommending weight loss surgery
  • Undergo a physical and psychological test
  • Have your doctor demonstrate that all other medical conditions (like pituitary, thyroid, and adrenal conditions) have been ruled out as potential causes of the obesity

Bariatric surgery costs

Before you have surgery, it’s important to ask if you will be an outpatient or admitted as an inpatient. This will be the main factor in determining the cost of your surgery.

  • Inpatient. If you are admitted to the hospital for the surgery, it will be covered by Medicare Part A, and you will need to pay the Part A deductible ($1,409 in 2020).  If you experience complications and stay in the hospital for longer than 60 days, you will also need to pay a daily coinsurance. 
  • Outpatient. Most bariatric surgeries are performed as outpatient procedures and covered by Medicare Part B. However, you will still need to pay the Part B deductible ($198 in 2020) if you have not already done so that year. You will also be responsible for 20 percent of the cost of the procedure, and Medicare will pick up the remaining 80 percent.  

The cost of surgery will also depend greatly on whether you will need follow-up care. Additionally, your doctor may recommend follow-up care that is only partially covered by Medicare, or not covered by Medicare at all. You may have to pay for these expenses out of pocket. 

If you have supplemental insurance like Medigap, your plan may pick up the deductibles, copays, and consinsurance that come with your surgery in addition to charges for follow-up care. 

If you decide to forego Medicare or other insurance altogether, bariatric surgery can be quite expensive. For example, the lap band surgery costs about $14,500 while gastric bypass is around $23,000.

Bariatric surgery in Mexico 

If you cannot afford bariatric surgery in the United States because Medicare won’t pay for it, another option is to seek a high-quality, low-risk bariatric surgery in Mexico. One bariatric surgery center Americans frequent is the Mexico Bariatric Center in Tijuana, Mexico. While the rate of bariatric complications in the United States was 1.4 percent in 2017, it was just 0.5 percent at the Mexico Bariatric Center in the same year. 

If other methods of considerable weight loss have failed you, talk with your doctor about weight loss surgery and contact Medicare to see what your coverage options are. No matter which type of bariatric surgery you get or where, it will be a lifelong journey that requires commitment to a healthy lifestyle. 

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