What Medicare Covers for Bariatric Surgery

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This article was updated on February 17, 2021. 

Bariatric surgical procedures cause weight loss by restricting the amount of food the stomach can hold, causing malabsorption of nutrients, or by a combination of both gastric restriction and malabsorption. Bariatric procedures also often incur hormonal changes. Most weight loss surgeries today are performed using minimally invasive techniques (laparoscopic surgery).

The most common bariatric surgery procedures are gastric bypass, sleeve gastrectomy, adjustable gastric band, and biliopancreatic diversion with duodenal switch. Each surgery has its own advantages and disadvantages.

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.

Bariatric surgery and mental health

Bariatric surgery can be very effective with type 2 diabetes, even putting it in remission. While there are life-changing aspects of the surgery, there are also other effects of which those considering it should be aware. Those effects have to do with mental health, alcohol, and drugs.

The surgery changes the way you metabolize food and alcohol, and changes the way your body looks. While your new body will be a positive thing, it also may be emotionally difficult to get used to these changes. There will be new habits, sagging skin, and perhaps weight loss that was not as drastic as you imagined.

Thoughts of self harm

A study, published in JAMA Psychiatry, examined 25,000 patients who had gastric bypass surgery, and followed up with them over a 10-year period. Of these patients, there was a five-fold increase in emergency room visits for self-harm. There was also an overall increase in the use of mental health services. The risk was even higher for those who experienced complications with their surgery or who had previous mental health problems.

“Patients with prior histories of major psychiatric illness, self-harm or eating disorders are probably at greatest risk and should have a period of mental health stability and professional psychiatric input before even being considered for bariatric surgery and then regularly followed up by their mental health teams post-operatively,” said David Morgan of St. John of God Subiaco Hospital in Australia.

Drug and alcohol abuse

Another recent study examined the effects of drugs and alcohol on those who have undergone bariatric surgery. The physiological changes after gastric bypass leave the stomach less chance to metabolize alcohol. After weight loss surgery, the body processes alcohol very differently, which can lead to becoming intoxicated with fewer drinks and becoming more emotional with alcohol.

So, before embarking on weight loss surgery, learn as much as you can, and be aware of the psychological effects it could have.

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 that 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). Duodenal switch is recommended for patients with a BMI of 50 or more. Patients with this procedure lose an average of 75 percent of their excess weight.
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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 comorbidity (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 ($1,484 in 2021).  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 ($203 in 2021) 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 coinsurance 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, 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.

The average cost of bariatric surgery in Mexico by procedure:

  • Lap Band – $3,000 to $6,500
  • Gastric sleeve – $4,000 to $9,000
  • Gastric bypass – $6,500 to $11,000

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 a commitment to a healthy lifestyle.

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