Does Medicare Cover Weight Loss Surgery?

When I was new to the Medicare industry, I would frequently ask what I thought was a simple and straightforward question. Just as frequently, I would be met with the answer, “it depends.”

With that as a backdrop, here we go: Medicare does cover bariatric surgery, but only for certain patients and only for certain types of procedures.

Let’s break it down. 

Who Is Eligible?

To qualify for coverage through Medicare, you must:

• Have a body mass index (BMI) over 35

• Have a history of unsuccessful attempts to lose weight without surgery

• Have one or more disease(s) that are related to the extra weight.

If you are unsure of your BMI, here is a calculator to help you.

Now that you have an idea of your BMI, let’s move on to the second requirement. Are you able to document your prior attempts to lose weight without resorting to surgery?  Since Medicare does cover counseling and behavioral therapy for consumers with a BMI of 30 or greater, you will need to explore this option before going straight to surgery as a solution. You will notice that this BMI is a lower threshold than the one required for the surgery.

Your primary care physician will be able to get you started, and this approach will focus on nutrition and exercise. I am not suggesting that Medicare will pay for a weight-loss program, such as Weight Watchers or Nutrisystem, because it won’t.  I am wanting to set your expectations that it will likely be a long and arduous process to get your request approved. In fact, when I was speaking about weight loss surgery with a surgeon that I personally know a few years back, he indicated that it was difficult to get these procedures approved.

Why do you think any insurance would be willing to pay for such a surgery? It would be because paying for the surgery would present a better value or outcome for you and for them than the prospect of them paying for related diseases exacerbated by the extra weight. Some examples of related diseases include high blood pressure, high cholesterol, type 2 diabetes, sleep apnea, stroke, heart disease, osteoarthritis, respiratory illness, gallbladder disease, and more.

Which Procedures Are Covered?

The types of bariatric surgery covered by Medicare include:

• Roux-en-Y gastric bypass
• Biliopancreatic diversion with duodenal switch
• Adjustable gastric banding
• Sleeve gastrectomy
• Vertical gastric banding

Some bariatric procedures are specifically excluded by Medicare, such as open sleeve gastrectomy and gastric balloon.

You may read more detail about the procedures and how they work.

How Much Does Weight Loss Surgery Cost?

As in many other scenarios, costs will vary widely.  You should expect a range of $15,000 – $25,000. 

That’s a lot of money, so you must be your own best advocate! Do not be afraid to ask questions of your doctor, hospital, or facility where the procedure is performed about what to expect, expected costs, follow-up care and its cost, etc. You may even wish to ask if you could get a discount by paying your portion of the fees up-front.

That’s right. You hopefully already know that just because insurance “covers” a procedure, that doesn’t mean you won’t have any charges. The deductible for Part A of Medicare is $1556 in 2022, the Part B deductible is $223, and Medicare only covers 80%.  You may have a supplement that will pay for some or all of these charges, or you may have a Medicare health plan that would have copays or a percentage you must pay.

Does Weight Loss Surgery Work?

According to the University of Iowa Hospitals and Clinics, success is “sometimes defined as achieving a 50 percent loss or more excess body weight and maintaining that level for at least five years.”

It’s hard to access hard numbers on successful outcomes, but research suggests that 66% – 80% of procedures are successful.

Summary

Medicare covers bariatric surgery, but it can be difficult to get approval, the procedures are expensive, and success isn’t guaranteed.  For those who are fortunate enough to receive treatment and experience successful outcomes, it can be a tremendous help in their overall health.