Does Medicare Cover Bariatric Surgery?
This article was updated on: 09/10/2018
Bariatric surgery is a type of weight loss surgery that may be recommended in some situations to treat obesity. Although there are different types, the procedure may involve surgically reducing the size of your stomach, so you will eat less food but feel full with less calories. Another type of procedure affects the way your stomach absorbs nutrients and metabolizes food.
Without insurance, the surgery can be very expensive. Original Medicare, Part A (hospital insurance) and Part B (medical insurance) may cover certain types of bariatric surgery if your doctor determines the treatment is medically necessary and you meet certain criteria set by Medicare.
Who qualifies for Medicare coverage for bariatric surgery?
Medicare covers certain types of bariatric surgery if you have certain factors related to morbid obesity. To be eligible, you must:
- Have a body mass index (BMI) of at least 35 kg/m2.
- Have at least one obesity-related medical condition, such as diabetes type 2.
- Have tried other treatments for obesity and been unsuccessful.
- Get the surgical procedure at a hospital or facility that has been certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center or as a Bariatric Surgery Center of Excellence.
What types of bariatric surgery does Medicare cover?
If you meet the eligibility criteria for bariatric surgery and your doctor determines that it’s medically necessary, you may be eligible for coverage. Keep in mind that Original Medicare Part A and Part B doesn’t cover every single type of bariatric surgery; for example, Intestinal Bypass surgery isn’t covered.
Medicare covers the following bariatric surgery procedures:
- Roux-en-Y bypass (gastric bypass) surgery is a two-part procedure that reduces the size of your stomach and then rearranges your intestines so that food transfers directly from your small intestine to your lower intestine. Because your stomach is physically smaller, you’ll need less food to feel full, resulting in weight loss. In addition, changing the digestive pathway also reduces the amount of food your body absorbs and affects your body’s gut bacteria. Generally, this weight loss surgery results in relatively high long-term weight reduction. Some of the potential risks involved in gastric bypass surgery include nutritional, vitamin, and mineral deficiencies; and “dumping syndrome,” where food moves too quickly from the stomach to the small intestine. Symptoms of dumping syndrome include nausea, weakness, sweating, fainting, and, occasionally, diarrhea after eating.
- Adjustable gastric band surgery places a band around the stomach to make it smaller. The band is an inflatable ring that can be adjusted as necessary, based on the patient’s weight loss progress. This is a reversible procedure and accomplished laparoscopically (a surgical technique that uses small incisions instead of a standard open surgery). The procedure is the least invasive of the Medicare-covered weight loss surgeries and generally involves a shorter recovery time and shorter hospital stay. However, a disadvantage may be slower weight loss than other weight loss surgeries.
- Gastric sleeve surgery shrinks your stomach size by forming it into a small sleeve using a stapling device and removing the rest of the stomach; roughly 80% of the stomach is removed with this procedure. Because portions of your stomach are removed, this surgery is irreversible.
- Duodenal Switch surgery (also known as Biliopancreatic Diversion with Duodenal Switch (BPD/DS) is a combination of a gastric sleeve and gastric bypass surgery. The surgery starts with a gastric sleeve to reduce the stomach size; then, the surgeon rearranges the intestines to reduce the amount of calories the body can absorb.
Bariatric surgery is considered a major procedure, and your risks vary depending on the type of surgery you get. Infection is a common risk, as well as nutritional deficiencies in some cases. Be sure to discuss the potential risks and benefits with your doctor if you’re considering bariatric surgery.
How much does bariatric surgery cost?
If you’re eligible for Medicare coverage of bariatric surgery, your costs will vary depending on your specific situation, the services you need, and how long you’re in the hospital. As mentioned above, keep in mind that you must get the surgery at a Medicare-approved facility to be covered.
Certain factors may affect your costs, including whether you’ll be covered through Medicare Part A as an inpatient or Medicare Part B as an outpatient. You may have deductibles, copayments, and/or coinsurance costs. Talk to your doctor beforehand so you understand how much the procedure may cost.
In general, bariatric surgery can be complex, which makes it a fairly costly procedure. Depending on the type of bariatric surgery you get, the average cost can range from $20,000 to $25,000, according to the UCSF Division of General Surgery website. This includes the cost for the surgeon’s services, as well as expenses related to pre-operative medical tests, anesthesia, and the hospital facility. After losing weight, some people choose to have body contouring plastic surgery to remove excess skin. This procedure may add several thousands of dollars on top of the cost of the weight loss surgery itself. Keep in mind that Medicare doesn’t cover cosmetic procedures unless it’s medically necessary to improve your body’s functioning, so make sure to check with your doctor so that you understand what your costs may be.
As mentioned, it’s a good idea to get an estimate of costs from your doctor as well as information regarding whether the procedure will be performed in an outpatient surgery or in the hospital. Verify your insurance coverage before scheduling any surgical procedure. Before Medicare will pay, you may have to pay the Part A and/or the Part B deductibles, plus any applicable copayments and coinsurance. If you have Original Medicare and a Medicare Supplement plan, find out how much your Medigap plan will pay of the cost not covered by Part A and Part B. If you are enrolled in a Medicare Advantage plan, your costs may be different; you may want to contact the plan to get an estimate of your out-of-pocket costs.
Would you like more information about how Medicare covers bariatric surgery? To learn more about these types of coverage and the options available where you live, feel free to contact me.
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