Does Medicare Cover Bariatric Sleeve Surgery?

Bariatric sleeve surgery can help individuals achieve significant weight loss and improve obesity-related health conditions. For those enrolled in Medicare, understanding how this federal health insurance program may cover such a procedure is important. While Medicare does not cover treatments for obesity alone, it can provide coverage for bariatric sleeve surgery when specific medical necessity criteria are met. This coverage addresses health complications arising from obesity, rather than purely cosmetic concerns.

Medicare Coverage Criteria for Bariatric Surgery

Medicare provides coverage for bariatric surgical procedures, including sleeve gastrectomy, when certain medical conditions and requirements are fulfilled. A primary criterion is a Body Mass Index (BMI) of 35 or greater.

Beyond the BMI requirement, beneficiaries must also present with at least one obesity-related comorbidity. These include conditions such as Type 2 diabetes, coronary artery disease, sleep apnea, or high blood pressure.

Another requirement involves a documented history of failed attempts at non-surgical weight loss. This means the individual must have participated in a medically supervised weight loss program without achieving sustained weight reduction.

To substantiate eligibility, comprehensive medical documentation is required. This includes physician notes, test results, and records from prior weight loss attempts. A psychological evaluation is also often necessary to assess readiness for surgery and commitment to post-operative lifestyle changes. A doctor’s referral for the bariatric surgery is also required.

Navigating the Medicare Approval Process

Initiating the Medicare approval process for bariatric sleeve surgery involves several administrative steps after medical criteria are met. The referring physician and bariatric surgeon typically submit a pre-authorization request to Medicare. This request serves as a formal justification for the planned procedure.

The pre-authorization submission package includes detailed medical records outlining the patient’s history and adherence to Medicare coverage guidelines. Accurate procedure and diagnosis codes must be included on these forms, often submitted electronically. Thorough documentation is important for review.

Once submitted, Medicare contractors review these pre-authorization requests. The processing time can vary. Additional information may be requested by Medicare, which can extend the review period.

Should a pre-authorization request or claim be denied, beneficiaries have the right to appeal the decision. The appeal process involves multiple levels, beginning with a redetermination by Medicare. Further appeals can be pursued if the redetermination is unfavorable.

Understanding Your Out-of-Pocket Costs

Even with Medicare coverage for bariatric sleeve surgery, beneficiaries will incur certain out-of-pocket costs. For Original Medicare (Part A and Part B), these expenses typically include deductibles, coinsurance, and copayments.

Medicare Part A, which covers inpatient hospital care, has a deductible of $1,676 per benefit period in 2025. After meeting this deductible, there is no coinsurance for the first 60 days of an inpatient hospital stay.

Medicare Part B covers outpatient medical services, including physician fees and surgical services. The annual deductible for Part B in 2025 is $257. After this deductible is met, Medicare generally covers 80% of the Medicare-approved amount, leaving the beneficiary responsible for the remaining 20% coinsurance. This 20% coinsurance can apply to services like surgeon’s fees and anesthesia.

Consider potential costs for services not fully covered by Original Medicare. For instance, certain pre-operative nutritional counseling or long-term post-operative psychological support might not be entirely covered, leading to additional expenses.

Medicare Advantage Plans and Bariatric Surgery

Medicare Advantage Plans (Part C) offer an alternative way to receive Medicare benefits and can also cover bariatric sleeve surgery. These plans are legally mandated to cover at least the same services as Original Medicare.

Many Medicare Advantage plans utilize managed care systems, which may require beneficiaries to use in-network providers for their care. They often have their own specific pre-authorization requirements and referral processes that must be followed for specialized services like bariatric surgery. Failure to adhere to these plan-specific rules could result in higher out-of-pocket costs or denied coverage.

Cost-sharing amounts, including copayments, coinsurance, and deductibles, vary widely among different Medicare Advantage plans. Unlike Original Medicare, Medicare Advantage plans also have an annual out-of-pocket maximum, which limits the total amount a beneficiary must pay for covered Part A and Part B services in a year. In 2025, this maximum cannot exceed $9,350 for in-network services, though individual plans may set lower limits. Individuals with a Medicare Advantage plan should contact their plan provider for accurate information.