Does Medicare Cover Weight Loss or Bariatric Surgery?
Key Takeaways
- Weight loss surgery — also known as bariatric surgery — may provide a solution for some people struggling with the impact of obesity.
- Medicare covers three types of bariatric surgery for patients that meet the requirements for coverage in terms of Body Mass Index, complicating conditions (known as comorbidities) and history with other weight-loss methods.
- Part A of Original MedicareOriginal Medicare is a fee-for-service health insurance program available to Americans aged 65 and older and some individuals with disabilities. Original Medicare is provided by the federal government and is made up of two parts: Part A (hospital insurance) and Part B (medical insurance). covers hospital-related expenses; Part B covers medically necessary treatments, services, and equipment; Part D covers drugs not covered by Parts A or B.
- All Medicare parts require that you cover some of the associated costs, premiums, deductibles and coinsurance.
- Medicare AdvantageMedicare Advantage (Medicare Part C) is health insurance for Americans aged 65 and older that blends Medicare benefits with private health insurance. This typically includes a bundle of Original Medicare (Parts A and B) and Medicare Prescription Drug Plan (Part D). can replace Original Medicare while offering at least the same coverage as Parts A and B along with additional coverage options.
Obesity has become a national health epidemic, one that the field of bariatric medicine is committed to curbing.
Does Medicare cover bariatric surgery? Yes, in some instances.
The National Health and Nutrition Examination Survey found that from 2017-18, 42.8 percent of Americans age 60 and older were obese; 5.8 percent were severely obese. Body Mass Index (BMI) considers people with a score of 30 or more as obese, while severe obesity is a BMI of 40 or more.
Medicare approves several surgical procedures for weight loss for people with a BMI of 35 or more.
Find the Medicare Plan that works for you.
Find My Ideal Plan
What Kind of Weight Loss Surgery Does Medicare Cover?
Surgery that helps reduce caloric intake and absorption has become a popular and effective treatment for people who haven’t had success with less invasive treatments. Surgical approaches continue to develop, and at this time, Medicare covers three types of surgery for eligible patients.
Does Medicare cover gastric bypass surgery, the oldest form of weight loss surgery? It does, in addition to a couple of newer procedures.
Roux-en-Y gastric bypass (open or laparoscopic) is a type of gastric bypass surgery more than a half-century old. The procedure creates a smaller stomach and a smaller path through the small intestine, leading to decreased hunger and food absorption.
Biliopancreatic Diversion with Duodenal Switch or Gastric Reduction Duodenal Switch (open or laparoscopic): is the most effective surgical weight loss approach for diabetes patients. The procedures work similarly to gastric bypass but remove large portions of the stomach rather than just bypassing it and may also remove most of the duodenum (the first portion of the small intestine).
Adjustable gastric banding (laparoscopic): The least invasive of the Medicare-approved procedures, sometimes used with less severe patients, places a silicone band around the top portion of the stomach that limits hunger and consumption.
(Note: “Open” procedures feature one large incision; “laparoscopic” procedures feature several tiny, targeted incisions.)
How Can I Get Medicare to Pay for Weight Loss Surgery?
The Centers for Medicare & Medicaid Services (CMS) Medicare Coverage Database outlines approved procedures. Approved bariatric procedures are covered for beneficiaries that,
- Have a body-mass index of more than 35
- Have at least one co-morbidity related to obesity
- Have been unsuccessful with medical treatment for obesity.
Medicare qualification for weight loss surgery actually will be determined on a case-by-case basis, meaning that the answer to the question, “Does Medicare cover weight loss surgery?” doesn’t always have a black-and-white answer despite the guidelines offered by CMS.
That means there’s a possibility that someone with a 35-plus BMI, a co-morbidity, and a previous failed attempt with medical treatment for obesity still won’t be covered by Medicare. Still, that determination should be made before surgery if at all possible to avoid unexpected costs.
For example, a laparoscopic sleeve gastrectomy may not be approved nationally but may be available locally. According to Medicare, local Medicare administrative contractors can approve a laparoscopic sleeve gastrectomy on a case-by-case basis.
Can I bundle multiple benefits into one plan?
See My Options
How Much Does Bariatric Surgery Cost with Medicare?
A 2017 study posted on the National Institutes of Health website put the average bariatric surgery cost (in 2016 dollars) at around $14,000 but with a standard deviation of more than $5,000.
Weight loss surgery costs will vary based on various factors, but if Medicare approves the procedure, you will pay some, but a relatively small portion, of the typical weight loss surgery cost.
Most people receive bariatric surgery on an inpatient basis, but outpatient weight loss surgery is more common each year.
- Of the nationally approved Medicare procedures, laparoscopic adjustable gastric banding is the least invasive and the most likely to be performed on an outpatient basis.
- Biliopancreatic Diversion with Duodenal Switch/Gastric Reduction Duodenal Switch are the most invasive and the most likely to be performed on an inpatient basis.
- Roux-en-Y gastric bypass may be outpatient in a few instances but more often remains inpatient.
For the patient, an outpatient procedure indicates that recovery might be more manageable. And for practical purposes, it will help determine how and what Medicare pays for the procedure. Interestingly, based on an average cost, a patient on Original Medicare may pay less out of pocket for an inpatient procedure.
- Part A of Original Medicare, known as hospital insurance, covers inpatient surgery. Patients are typically responsible for the benefit period deductible but only have to pay coinsurance if the hospital stay tops 60 days. There may be some Part B cost responsibilities as well.
- Part B of Original Medicare, known as medical insurance, covers outpatient surgery. With Part B, patients typically are responsible for 20% coinsurance after paying their annual deductible, while Medicare pays 80% of the costs. Expenses incurred after the surgery, in most cases, will fall under Part B as well.
Alternatively, having Parts A and B allows you to switch to Part C (Medicare Advantage). Your costs may be different with Medicare Advantage. However, your plan will provide at least the same coverages as Parts A and B. Medicare Advantage plans from private insurance companies replace Parts A and B. It may provide additional coverage related to bariatric surgery, including drug costs. Costs will vary from one plan to another, but all Medicare Advantage plans feature an out-of-pocket maximum for the plan year.
How Long Does it Take Medicare to Approve Weight Loss Surgery?
Medicare technically doesn’t put a time frame on approval for weight loss surgery. Medicare, like other health insurance entities, expects due diligence before approving surgery.
A still-recognized 2006 CMS decision memo states:
“The standard of care for any surgical procedure is that medical management options are exhaustively considered and exercised by both patient and physician before surgery. This standard applies to the treatment of co-morbid conditions related to obesity. We will not impose a specific period, but expect all surgeons to be part of a comprehensive program for the treatment of co-morbid conditions related to obesity and to have applied principles of good medical care before surgery.”
What is the wait time for bariatric surgery using Medicare?
There is no set time for Medicare to approve weight loss surgery, but it’s a surgery that your doctor or Medicare doesn’t enter into lightly.
Facilities that perform bariatric surgery have real-world experience working with Medicare and other insurances and know what it takes to get approval for weight loss surgery.
So even though Medicare states that the only pre-surgery requirements are:
- A BMI of 35 or more
- At least one co-morbidity related to obesity
- An unsuccessful medical treatment for obesity
So while Medicare doesn’t explicitly have a waiting period for bariatric surgery, facilities that work with Medicare can provide some perspective.
Will Medicare Pay for Skin Removal After Weight Loss Surgery?
Medicare doesn’t cover cosmetic surgery, but it may cover cosmetic procedures if they are medically necessary for a particular situation.
Medicare lists a panniculectomy, defined as “surgery to remove excess skin and tissue from the lower abdomen,” among a list of outpatient services that may be covered “because of accidental injury or to improve the function of a malformed body part.”
As with bariatric surgery and other surgical procedures, you should work with your healthcare provider to determine if Medicare will cover the procedure.
Ready for a new Medicare Advantage plan?
Get Help Now
Sources
- Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. CDC.gov.
- Bariatric Surgery Procedures. American Society for Metabolic and Bariatric Surgery.
- National Coverage Determination (NCD) for BARIATRIC SURGERY for Treatment of Co-Morbid Conditions Related to Morbid Obesity (100.1). CMS.gov
- What Are the Real Procedural Costs of Bariatric Surgery? A Systematic Literature Review of Published Cost Analyses. National Institutes of Health.
- Decision Memo for Bariatric Surgery for the Treatment of Morbid Obesity (CAG-00250R). CMS.gov.
- Your Medicare Benefits. Medicare.gov.
This website is operated by GoHealth, LLC., a licensed health insurance company. The website and its contents are for informational and educational purposes; helping people understand Medicare in a simple way. The purpose of this website is the solicitation of insurance. Contact will be made by a licensed insurance agent/producer or insurance company. Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. Our mission is to help every American get better health insurance and save money.
Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.