Getting Medicare to Cover Weight Loss Surgery: Who Is Eligible?
Fact checked by Nick BlackmerMedically reviewed by Kelly Wood, MD
If you have obesity, you may consider weight loss surgery, referred to as bariatric surgery. While Medicare does not cover medications such as Ozempic and Wegovy (semaglutide) for the purpose of weight loss, it may cover some bariatric surgeries.
The American Medical Association (AMA) first recognized obesity as a disease in 2013. Today, obesity affects as many as 42% of Americans, and many of them have medical conditions associated with the extra weight.
This article explains the requirements for Medicare eligibility for weight loss surgery, the types of surgery covered, possible out-of-pocket costs for Medicare Parts A, B, and C, and what to do if your surgery doesn't qualify for Medicare coverage.
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Medicare Eligibility Criteria for Weight Loss Surgery
Medicare requires that certain criteria be met before they will cover bariatric surgery.
Medical Requirements
You must meet all three criteria below:
You have a body mass index (BMI) greater than or equal to 35.
You have at least one medical condition related to obesity.
You have tried other medical treatments for obesity, but they were unsuccessful.
Gastric bypass is not covered when it is performed as a treatment for obesity alone. Anyone having the procedure must also have medical complications caused by or exacerbated by their obesity.
Examples of comorbidities (co-occurring health conditions) include, but are not limited to, diabetes, gastroesophageal reflux disease (GERD), hypertension (high blood pressure), osteoarthritis (wear-and-tear arthritis), and sleep apnea (stopping and restarting breathing as you sleep). Your surgeon must clearly document the medical conditions they are treating with surgery.
Institutional Requirements
To decrease the risk for complications, Medicare has strict rules on who can perform these weight loss surgeries and where they can perform them, as follows:
Surgeons: Your surgeon must be board-certified by the American Society for Bariatric Surgery. They must have performed at least 125 bariatric surgeries in their lifetime, with at least 50 surgeries performed in the year before your surgery.
Facility: Each institution must perform at least 125 of these surgeries every year. They must have adequate staff and consultative services to educate anyone interested in or who has had surgery at their facility. They must also organize and supervise support groups and offer a program with long-term follow-up.
Types of Weight Loss Surgery Possibly Covered Under Medicare
Medicare is specific about the types of bariatric surgeries it will cover. After reviewing the medical literature and evidence-based research, Medicare will cover the following surgeries based on their ability to sustain weight loss, their effectiveness in treating comorbidities, and their overall risk versus benefit when it comes to surgical complications and mortality:
Biliopancreatic diversion without duodenal switch
Medicare has not found sufficient evidence to support the following procedures and does not cover them:
Vertical banded gastroplasty
How to Get Medicare Coverage for Weight Loss Surgery
You must have the documentation to show you qualify for bariatric surgery.
The Centers for Medicare & Medicaid Services does not specify which treatments and how long you had to have tried them to be considered “unsuccessful.” What is important is that you have your treatment attempts documented by a medical professional whenever possible.
Weight Loss Medications
The irony is that Medicare does not cover weight loss medications as an approved intervention even though you need to have tried weight loss treatments to qualify for surgery. Medicare could still pay for a medication that promotes weight loss if it’s being used to treat another condition, such as Ozempic for diabetes.
It can be helpful to participate in Medicare’s preventive health services, specifically their intensive behavioral therapy program for obesity. Under this program, Medicare Part B covers counseling with your primary care provider to coordinate a weight loss plan for you based on diet and exercise.
Visits can occur as often as weekly in the first month and every other week for the next five months. If you lose 3 kilograms (kg), which equals 6.6 pounds, during that time, you can go on to have monthly visits. These supervised weight loss visits can help support your need for surgery.
Although Medicare does not cover other weight loss or lifestyle programs like Jenny Craig, Noom, or WW (formerly Weight Watchers), you could provide documentation that shows you participated in these programs. The more details provided about your attempts, the better.
Possible Out-of-Pocket Costs
Even when Medicare covers your surgery, there will still be out-of-pocket costs. These can include deductible, co-pays, and coinsurance.
Part A
The gastric bypass and biliopancreatic surgeries covered by Medicare are on the Inpatient Only List. This means they will be covered by Medicare Part A no matter how long you stay in the hospital. You will pay a deductible for your hospital stay ($1,632 in 2024) and 20% of any physician fees.
Other surgeries may be considered for Part A coverage, too. This could be the case if your surgeon documents that you are at high risk for surgery and your hospital stay is expected to cross at least two midnights. This is based on what is known as the two-midnight rule.
Part B
Surgeries that are not on the Inpatient Only List and that do not satisfy the two-midnight rule will be covered by Medicare Part B. In that case, you will pay 20% for each service during your hospital stay, including physician fees.
Unlike the flat rate you pay for Part A surgeries, you will pay costs for the surgery itself, laboratory tests and imaging, medications, nursing care, room and board, and any other services you receive for each day you are in the hospital. No individual service can cost more than the Part A deductible ($1,632 in 2024), but together, they add up.
Plastic Surgery
When people lose a lot of weight, excess skin and tissue can be left behind. The extra skinfolds can be distressing for some people. Medicare generally considers the removal of this skin to be a cosmetic procedure and does not cover it.
An exception would be if you have had repeated infections or ulcerations of the skin in those areas that have not responded to other treatments. This would be a medical indication for the procedure, not a cosmetic one.
Medicare Advantage (Part C)
Medicare Part C, also known as Medicare Advantage, is an alternative to Original Medicare (Part A and Part B). Instead of being overseen by the government directly, these plans are run by private insurance companies with federal oversight.
They cover everything that Original Medicare does, including the bariatric surgeries discussed in this article. However, what you pay for these surgeries may vary depending on your plan. You will want to reach out to your plan to discuss your expected out-of-pocket costs.
If You Don’t Qualify for Medicare But Need Help
To be eligible for Medicare, you need to be at least 65 years old or have a qualifying disability. You also need to be either a U.S. citizen, a legal resident of the United States for at least five consecutive years, or a legal immigrant who has paid sufficient Social Security taxes to qualify for Social Security Insurance.
Average Bariatric Surgery Costs
Without insurance, bariatric costs range from $7,400 to $33,000. These costs vary based on how complicated the procedure is, less expensive for sleeve gastrectomy and lap banding and more expensive for gastric bypass and biliopancreatic surgeries.
If you don’t qualify for Medicare, you will want to look into other insurance options. Consider Healthcare Marketplace plans, Medicaid, or private insurance.
You could also consider a medical loan. If you have a financial need, your surgeon may be able to refer you to a grant that could help pay for your expenses.
Summary
With rising rates of obesity, more people will consider weight loss surgery. Medicare covers certain procedures as long as criteria are met, namely having a BMI greater than or equal to 35, obesity-related conditions, and trials of nonsurgical treatments. Costs will vary based on the type of bariatric procedure performed and where it’s covered by Medicare Part A or Part B.
Read the original article on Verywell Health.
