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 health insurance companies 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.