Does medicare cover bariatric surgery? Do they cover gastric sleeve surgery? Is there a co-pay?
According to Medicare, they do cover bariatric surgeries as long as the patient applying for approval fits their requirements. Their requirements include the patient having a body mass index (BMI) over 35 and at least one co-morbidity related to obesity. Comorbidity is a disease that is a result of one’s obesity. These co-morbidities can include: Type II Diabetes, high blood pressure, high cholesterol, obstructive sleep apnea, soft tissue infections, depression, stroke or risk of stroke, GERD and Gallbladder Disease, just to name a few.
The patient must also have documentation in their medical records confirming they have tried to lose weight in the last 12 months without success. If all of these things apply to this patient, they are eligible for coverage.
Medicare Approved Surgery Types
Medicare offers gastric sleeve, lap band (or Realize Band), biliopancreatic diversion with the duodenal switch as well as gastric bypass surgeries for eligible patients. It’s important to note that gastric sleeve is covered on a regional basis, so have your bariatric surgeon call your local Medicare office for approval. Gastric balloon surgery is not approved at this time.
To get approved, you will first need to be referred by your primary care physician to a weight loss surgeon (choose one in-network for less of a chance of any out-of-pocket expenses). In their referral, they must mention your obesity-related health problems that they expect to improve with this type of surgery. You will need to choose a facility that meets their specific minimum facility standards and certification requirements (double check with Medicare directly).
After you find an experienced and approved surgeon, you will need to go through all of the required tests to prepare for surgery. Some tests may include x-rays, stress tests, EKG, mental evaluation, physical evaluation and various lab work tests. This approval is necessary to be approved by Medicare coverage. Your physician and surgeon will give you all of the necessary details associated with the process and provide a checklist of things to complete to be fully prepared.
You can often obtain pre-authorization with the help of your physician. Your surgeon will be the one directly contacting Medicare to provide them with documentation and information needed to get your surgery approved. While the process can be lengthy, your surgeon is ultimately the one responsible for getting you approved after you do all the steps needed to get there.
The amount of the procedure that is covered will depend on the plan that you have. Most plans include at least 80% of the surgery cost. The rest may even be covered by MediGap, which is a supplemental plan that leaves patients with no expenses associated with their specific weight loss surgery procedure.
According to Medicare directly, all Medicare patients should also log in to their MyMedicare.gov account and see if they have met their deductible. First, check the Part A deductible if you are going to be admitted to the hospital. Next, check your Part B deductible for any outpatient care and doctor visits (follow-up visits). You will need to pay the deductible amounts listed before Medicare starts to pay.
A professional weight loss surgeon fully understands the approval process and is committed to helping you, the patient, to succeed at getting approved and the surgery you need to change your life.