Does Medicare Cover Bariatric Surgery?
Bariatric surgery is a popular type of weight loss surgery that many turn to when they feel that diet and exercise isn’t enough to help them shed the pounds that they want or need to lose. As with any surgery, though, it can be expensive, especially if you don’t have insurance coverage. With weight being an issue for many seniors, bariatric surgery may be of interest, but unaffordable. That begs the question, does Medicare cover bariatric surgery? The answer is a little complex.
What is Bariatric Surgery?
First, let’s discuss what bariatric surgery is, because that may help to explain whether or not Medicare covers it. Bariatric surgery isn’t one surgery; it’s an umbrella term for a range of weight loss surgeries that can include gastric bypass, a gastric sleeve, and an adjustable gastric band (the three most common types of bariatric surgery). Generally, people turn to bariatric surgery if lifestyle or diet changes haven’t worked for them in the past.
Bariatric surgeries aid in weight loss in at least one of two ways. They can physically limit the amount of food you can eat or reduce your body’s ability to absorb nutrients from food and drink. There are some procedures that do both. Of course, bariatric surgeries can still fail to help you lose weight if you don’t make healthier changes to your diet and lifestyle after the surgery. It’s important to work with your doctor after the surgery to ensure ongoing success.
Eligibility Criteria for Medicare Coverage of Bariatric Surgery
Medicare should help cover bariatric surgery if you meet the eligibility criteria. You can find this criteria in the Centers for Medicare & Medicaid Services’ (CMS) national coverage determination, along with updates to that coverage determination. Generally, for bariatric surgery to be covered…
- Your body-mass index (BMI) must be greater than 35.
- You must have at least one co-morbidity related to obesity.
- You must have had unsuccessful medical treatment for obesity in the past.
If you fit those circumstances, your bariatric surgery may be covered by Medicare. Why did we only say “may be covered by Medicare? Not every bariatric surgery is covered by Medicare. In fact, the following bariatric surgeries are not covered by Medicare:
- Open adjustable gastric banding
- Open sleeve gastrectomy
- Laparoscopic sleeve gastrectomy (prior to June 27, 2012)
- Open and laparoscopic vertical banded gastroplasty
- Intestinal bypass surgery
- Gastric balloon for treatment of obesity
Thankfully, there are a few surgeries that Medicare covers. Bariatric surgeries covered by Medicare can include:
- Open and laparoscopic Roux-en-Y gastric bypass
- Laparoscopic adjustable gastric banding
- Open and laparoscopic biliopancreatic diversion with a duodenal switch
- Stand-alone laparoscopic sleeve gastrectomy
Of course, there’s always the possibility that the requirements and covered surgeries may change, so before having bariatric surgery, it’s worth talking to your doctor to get the latest information and discuss which surgery is the best for you.
What is Your Status?
Even if Medicare will cover your bariatric surgery, how it does so can vary based on a few factors, namely, where you get the surgery. A bariatric surgery can be performed in both an inpatient and outpatient setting, which changes which part of Medicare covers your surgery. Much like with observation status, you could have your surgery at a hospital and still have it covered by Medicare Part B, since you’d be counted as an outpatient. Bariatric surgeries can also be given in other outpatient facilities like ambulatory surgery centers. Where you have the surgery depends on how much you’ll owe out-of-pocket through Medicare.
Let’s go with the lower end of the typical cost range, which is $20,000. If this treatment is given as part of inpatient care, you’ll owe your Medicare Part A deductible (unless you’ve already met it for the year) and a coinsurance for any days spent in the hospital if you’re there longer than 60 days. The Part A deductible is $1,484 in 2021. Patients generally spend two to five days in the hospital recovering from a surgery, so you’re unlikely to experience a coinsurance under Original Medicare. Some Medicare Advantage plans may have a daily copay, though this differs from plan to plan.
If you got that same bariatric surgery in an outpatient setting, Medicare Part B would help cover it, instead of Part A. In this case, you’d be paying the Part B deductible of $203 (unless you’ve already met it for the year). Once you’ve met the deductible, you’ll generally pay a Part B coinsurance of 20 percent of the Medicare-approved amount. In our example, that would be $4,000, along with a coinsurance for any other services that may come along with the surgery. This means your surgery will at least cost roughly $4,203, though this could go higher if you have other things to pay for along with your surgery.
The Original Medicare costs in this section can be found at our article Here’s What Medicare Costs in 2021.
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It’s so important to talk to your doctor before getting a bariatric surgery. Not only may it not be necessary, the ultimate cost of the surgery (even with Medicare coverage) can be highly variable. While a bariatric surgery may be able to help you lose weight, unless you fit the criteria for Medicare coverage or have another form of coverage, the surgery may be prohibitively expensive.