Does Medicare Cover Bariatric Surgery?

Bariatric surgery serves as a treatment option for individuals with severe obesity who have not achieved sustainable weight loss through other methods. These procedures modify the digestive system to help reduce food intake and nutrient absorption, leading to significant weight reduction. For many, understanding Medicare’s coverage for these complex and transformative surgeries is an important first step.

Medicare’s General Coverage Criteria

Medicare provides coverage for bariatric surgery when specific medical necessity criteria are met. Beneficiaries must typically have a Body Mass Index (BMI) of 35 or higher. This threshold requires at least one obesity-related co-morbidity. Common co-morbidities that qualify include type 2 diabetes, severe sleep apnea, heart disease, high blood pressure, high cholesterol, osteoarthritis, gallbladder disease, and certain types of cancer. Furthermore, there must be a documented history of unsuccessful medical treatment for obesity, such as participation in physician-supervised weight loss programs. This criterion ensures that surgery is considered after other less invasive interventions have been attempted without success.

Specific Surgical Procedures and Facility Standards

Medicare covers open and laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch (both open and laparoscopic). Certain procedures are not covered by Medicare, such as open sleeve gastrectomy, open adjustable gastric banding, open and laparoscopic vertical banded gastroplasty, intestinal bypass surgery, and gastric balloon procedures. Regarding facility standards, Medicare previously required bariatric surgeries to be performed in facilities designated as Centers of Excellence. This certification requirement was removed, expanding options for beneficiaries.

Navigating the Pre-Surgical Approval Process

Securing Medicare coverage for bariatric surgery requires thorough documentation and evaluation. While Medicare does not use a “pre-authorization” process like many private insurers, comprehensive submission of medical records is essential for coverage. Patients and providers must prepare evidence to demonstrate eligibility. The process often begins with a referral from a primary care physician, followed by extensive medical evaluations. These evaluations may include blood tests to assess adrenal, thyroid, and pituitary function. Patients typically undergo psychological assessments to evaluate readiness for surgery and the long-term lifestyle changes required. Nutritional counseling is also a common requirement, providing education on postoperative eating behaviors and often necessitating documented participation in a medically supervised weight loss program for several months.

Financial Considerations and Denials

Even with Medicare coverage, beneficiaries are responsible for certain out-of-pocket costs associated with bariatric surgery. These costs include deductibles, co-insurance, and co-payments. For instance, in 2025, the Medicare Part A deductible for inpatient hospital stays is $1,676 per benefit period, and daily co-payments can apply for extended stays. For outpatient services, covered under Medicare Part B, the 2025 deductible is $257, and beneficiaries typically pay 20% co-insurance after the deductible is met.

The total out-of-pocket expenses can vary significantly based on whether the surgery is performed on an inpatient or outpatient basis, the specific services rendered, and whether the beneficiary has supplemental insurance like a Medigap policy or a Medicare Advantage plan. Medicare Advantage plans must cover at least the same benefits as Original Medicare, but their cost-sharing structures, such as premiums, deductibles, and co-payments, can differ.

If Medicare initially denies coverage, beneficiaries have the right to appeal the decision. The appeals process involves multiple levels and requires understanding the reason for denial, gathering additional supporting documentation, and submitting a formal appeal.