Does Medicare cover bariatric surgery?

If you are considering weight loss surgery, you probably know that it is an expensive proposition. Just how expensive? Average costs in the United States for the four most common types of bariatric surgery are:

  • gastric bypass – $24,000
  • gastric banding – $15,000
  • gastric sleeve – $19,000
  • duodenal switching – $27,000

Keep in mind that these costs may not include pre-operation, post-operation, or follow-up office visits.

Given the high price tag, you may be wondering if Medicare can help you with some or all of the expenses. The answer is yes, with a few qualifications. When you meet certain conditions related to morbid obesity, Medicare will cover gastric bypass surgery, laparoscopic banding surgery, lap band or realize band surgery, duodenal switch, and sleeve gastrectomy procedures. Sleeve gastrectomy procedures, however, are only offered on a regional basis.

Conditions for coverage

In order for Medicare to cover your weight loss surgery, you must have a body mass index (BMI) of 35 or higher. You must also have at least one co-morbidity, which is defined as a serious illness related to your obesity. Examples of serious obesity-related illnesses include sleep apnea, high blood pressure, and diabetes. In addition to the BMI and the illness requirements, you must provide documented evidence that you have been obese for the past five years. You must also provide evidence that you have participated in a medically supervised weight loss program and that you have failed more than one program. You must pass a psychological evaluation, and you must obtain a letter from your doctor that recommends you for weight loss surgery. Finally, you must provide evidence from your doctor stating that all other treatable diseases have been ruled out as causes of your obesity. This requirement may include thyroid, pituitary, or adrenal screening tests.

Though the average costs figures mentioned above are accurate as of 2016, your individual costs may be different. Every patient is different, so it’s difficult to know exactly how much your procedure will cost. You should consult with your doctor or hospital to determine which procedure is right for you as well as the total costs involved. The total cost will include the procedure itself and any necessary post-op care. Be sure to ask your doctor if you will be considered an inpatient or an outpatient, since Medicare handles payment for those services differently. If your doctor expects you to be admitted to a hospital, you should check your Medicare Part A deductible and plan accordingly. If you’ll be treated on an outpatient basis, check your Part B deductible. After you have paid the appropriate deductible, Medicare will kick in for the remainder of the procedure. You may be responsible for additional copayments depending on your particular coverage.

Most original Medicare plans cover 80% of the Medicare-approved cost for a given surgery. If you need additional financial assistance, consider a Medicare Advantage Plan (also called Plan C), or a Medigap private insurance plan. We can connect you with an insurance agent that will help you through the process of finding additional plans that provide the weight loss surgery coverage that you need.

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