Medicare Bariatric Surgery Requirements

What are Medicare Bariatric Surgery Requirements? Do you qualify for Medicare’s bariatric program?

Medicare does cover bariatric surgeries as long as the patient qualifies according to their requirements. The patient must have a body mass index (BMI) greater than 35, have at least one co-morbidity related to obesity (see list below) and have documentation in their medical records confirming that they have tried to lose weight on their own with no success. If all of these things apply, the patient may apply for one of these weight loss surgery options:

  1. Gastric sleeve
  2. Gastric bypass
  3. Lap band
  4. Biliopancreatic diversion with duodenal switch>

NOTE: Medicare does not cover the gastric balloon surgery at this time.

What are Co-Morbidities?

A comorbidity is a disease that is a result of one’s obesity. Examples of co-morbidities include (and are not limited to):

  • Sleep apnea
  • High blood pressure
  • High cholesterol
  • Type II Diabetes
  • Soft Tissue Infections
  • Arthritis
  • Fatty Liver Syndrome
  • Gallbladder Disease
  • Depression
  • Stroke/Stroke Risk
  • GERD

How to Get Approved For Weight Loss Surgery with Medicare

In order to get approved, you will need to be referred by your primary care physician. In their referral to a bariatric surgeon, they need to refer to your obesity healthy problems that are expected to improve following this type of surgery. You will need to choose a facility that meets their minimum facility standards and certification requirements. Contact them directly during this decision-making process. Regardless of what Medicare plan you have, talk directly with your surgeon to make sure they accept your insurance.

Generally, the amount of the procedure covered will depend on the plan you have. Most plans cover at least 80% of the amount of the surgery. The rest may be covered by MediGap supplemental plan leaving you with no expenses associated with your bariatric surgery.

After you find a qualified and approved surgeon, you will need to go through all of the required tests such as x-rays, mental evaluations, physical evaluations and lab work. This approval is important to being approved by Medicare for your coverage. Your physician can give all of the details associated with the entire process and provide a checklist for you to follow. You can obtain pre-authorization with the help of your physician. The surgeon will contact Medicare and provide them with the necessary documentation and/or information needed in order to have your surgery approved. The process can be lengthy and your surgeon will be the one responsible for this approval process. Medicare may even ask you additional questions in order to finalize the approval process and to pay for your surgery.

Ultimately, a professional bariatric surgeon understands the process and is dedicated to helping you, the patient, succeed at getting approved and enduring weight loss surgery that will change your life.