If you’re working with a doctor to lose weight, Medicare may cover gastric bypass surgery.
Weight loss surgery isn’t right for everyone, and it’s typically the last resort for those looking to lose weight. However, there are several different types of bariatric surgery, including gastric bypass surgery, that can help a person lose weight and get healthier. Thousands of people get bariatric surgery each year in the U.S.
While these procedures can be very expensive, Medicare does cover some of the costs for qualified beneficiaries. Read on to learn more about Medicare coverage for gastric bypass surgery and other information you may need to know.
Medicare coverage for gastric bypass surgery
Some bariatric surgical procedures, including gastric bypass surgery, are covered by Medicare as long as you meet certain criteria related to morbid obesity. This includes:
- A body mass index (BMI) of 35 or higher
- At least one comorbid condition resulting from obesity
Examples of comorbid conditions resulting from obesity include insulin resistance, diabetes, hypertension, sleep apnea, arthritis, gall bladder disease, certain types of cancer, and others.
Additionally, beneficiaries may also have to provide the following information to qualify for Medicare coverage:
- The results of thyroid, adrenal, and pituitary blood tests showing results within a standard range (to rule out a treatable, medical disease as a possible cause for your obesity)
- Results of a psychological evaluation
- Proof of participation in at least one unsuccessful weight loss program (that was medically supervised)
- A doctor’s referral
If the above conditions are met and the procedure is performed at a facility certified by either the American College of Surgeons or the American Society for Bariatric Surgery, services related to the surgery (including diagnosis, procedure, and recovery) will be covered. Examples include:
- Durable medical equipment (DME) needed during recovery
- Exams prior to the procedure
- Inpatient hospital care following the procedure
- Lab testing
- Surgical services performed during the procedure
- Visits to your doctor and/or other specialists during recovery
Medicare Part A would cover the hospital services you need, including the hospital stay for your surgery and services you need while in the hospital. Medicare Part B covers any medical services and outpatient care you’d need before and after the procedure. Medicare Part D (prescription drug coverage) would cover any medication you may need during recovery as well.
Related Reading: Does Medicare Cover Bariatric Weight Loss Surgery?
Do Medicare Advantage plans cover gastric bypass surgery?
Medicare Advantage plans (Part C) cover everything that would be covered under Original Medicare Part A and Part B. These plans are sold by private insurance companies, so they typically also offer additional benefits such as for vision, dental, and hearing.
Because Part C plans must cover the same things as Original Medicare, gastric bypass surgery would be covered. However, most MA plans have a network of providers you must use to be covered, so make sure you’re seeing providers within your network. You may also have different costs associated with the procedure or recovery.
Does Medigap cover gastric bypass surgery?
Medicare supplement plans, or Medigap, help fill the “gaps” in Original Medicare by covering things like deductibles, co-pays, and co-insurance. Medigap plans help cover many of the out-of-pocket costs associated with gastric bypass surgery, making the surgery more affordable for you.
Types of bariatric surgery
There are four different types of weight loss surgeries, all currently covered by Medicare:
- Gastric bypass surgery: During gastric bypass surgery, the surgeon turns the top of the stomach into a small gastric pouch. A loop of the small intestine is fed and connected into the gastric pouch, and the other end of the loop is reconnected to the small intestine. Food is then redirected into an area further into your digestive system, bypassing the stomach so your body won’t absorb as many calories.
- Sleeve gastrectomy: Also known as a vertical sleeve gastrectomy, this procedure is done laparoscopically. About 80% of the stomach is removed, leaving a tube-shaped stomach about the size of a banana. This restricts the amount of food you’re able to eat and helps prompt hormonal changes that assist with weight loss.
- Lap band surgery: The least invasive option, an adjustable gastric band is placed around the upper portion of the stomach to restrict how much food the stomach will hold, helping you to feel full faster.
- Duodenal switch: This procedure combines a sleeve gastrectomy with an intestinal bypass, removing part of your stomach to restrict how much food your stomach can hold and how much nutrition your small intestine can absorb.
Note that a sleeve gastrectomy may only be covered on a regional basis, so check with your local bariatric surgeon or Medicare for more information.
There are several risks and side effects of bariatric surgery, as well as complications from the procedure. It’s important to talk to your doctor to ensure you understand your options and know how to take care of yourself properly before and after the procedure. However, for most people, the benefits of weight loss and reducing weight-related problems outweigh the negatives.
How much does gastric bypass surgery cost?
You won’t know exactly what services you need until you meet with a provider, and costs can also depend on the hospital you have the procedure at, your surgeon, and other factors. Typical costs range from $20,000 to $25,000.
However, with Medicare, most of those costs will be covered. The out-of-pocket expenses you’d be responsible for may include:
- Your Part A deductible ($1,632 in 2024)
- Your Part B deductible ($240 in 2024)
- Other co-insurance and co-payment costs depending on your plan
Talk to your doctor or contact Medicare or your Medicare plan to learn more about specific costs you may be responsible for and payment options you may have.