Does Medicare Pay for Gastric Bypass Surgery?

Medicare provides health coverage for millions, and understanding its policies for complex medical procedures like gastric bypass surgery is important. Many individuals considering this type of surgery often wonder about the extent of their coverage. This article clarifies Medicare’s position on gastric bypass surgery, detailing the conditions for coverage, the necessary approval steps, and the financial obligations involved.

Medicare’s Stance on Bariatric Surgery Coverage

Medicare covers certain bariatric surgical procedures, including gastric bypass surgery, when these procedures are medically necessary. Both Original Medicare and Medicare Advantage plans may provide coverage if specific criteria are met. The principle for coverage is that the surgery must address health conditions related to obesity rather than treating obesity as a standalone condition.

Specific bariatric surgeries covered by Medicare include Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banding (LAGB), laparoscopic sleeve gastrectomy (LSG), and biliopancreatic diversion with duodenal switch (BPD/DS). While Medicare recognizes the benefits of these surgeries, it does not cover treatments solely for obesity without related health complications.

Meeting Medical Criteria for Coverage

Medicare beneficiaries must satisfy specific medical criteria to be eligible for bariatric surgery coverage. A requirement is a Body Mass Index (BMI) of 35 or higher. The individual must also have at least one obesity-related co-morbidity.

Common co-morbid conditions that may qualify a beneficiary include type 2 diabetes, severe sleep apnea, heart disease, high blood pressure, high cholesterol, osteoarthritis, stroke, or certain types of cancer. Medical documentation must demonstrate previous unsuccessful attempts at weight loss through medically supervised programs.

Preparatory steps include undergoing a psychological evaluation to assess readiness for surgery and commitment to lifestyle changes. Blood tests, such as those for thyroid, adrenal, and pituitary function, are typically required to rule out other medical causes for obesity.

Navigating the Coverage and Approval Process

Once medical criteria are met, the process of obtaining Medicare coverage for bariatric surgery begins with a referral from a primary care physician. This referral should detail the obesity-related health problems that are expected to improve following the surgery. The healthcare provider will seek pre-authorization or prior authorization from Medicare for the planned procedure.

A requirement for Medicare coverage is that the bariatric surgery must be performed at a facility designated as a Medicare-approved Center of Excellence (COE). These centers are certified by recognized organizations, such as the American College of Surgeons (ACS) or the American Society for Metabolic and Bariatric Surgery (ASMBS), ensuring they meet high standards for patient care and safety.

Should a claim for bariatric surgery coverage be initially denied, beneficiaries have the right to appeal the decision. The appeal process typically involves several levels, starting with a request for redetermination, followed by reconsideration, an Administrative Law Judge (ALJ) hearing, review by the Medicare Appeals Council (MAC), and potentially judicial review in federal court. To initiate the appeal within 120 days of receiving the denial notice, provide supporting documentation from healthcare providers.

Understanding Your Financial Responsibilities

Even with Medicare coverage, beneficiaries will incur out-of-pocket costs for gastric bypass surgery. For inpatient hospital stays covered by Medicare Part A, the deductible for each benefit period in 2025 is $1,676. After meeting this deductible, there is no coinsurance for the first 60 days of an inpatient stay. However, for days 61 through 90, a daily coinsurance of $419 applies, and for lifetime reserve days (up to 60 days), the daily coinsurance is $838.

Medicare Part B covers physician services, outpatient care, laboratory tests, and durable medical equipment associated with the surgery. The annual deductible for Medicare Part B in 2025 is $257. After this deductible is met, beneficiaries typically pay 20% of the Medicare-approved amount for most covered services, with Medicare covering the remaining 80%.

Certain costs are generally not covered by Medicare, such as cosmetic procedures like plastic surgery following weight loss, or transportation to and from the surgical center. Additionally, while some medically necessary weight management services may be covered, general weight loss programs or medications not directly tied to the surgical procedure are typically not. For those enrolled in Medicare Advantage (Part C) plans, out-of-pocket costs can vary, as these private plans may offer different cost-sharing structures and additional benefits, often including an annual out-of-pocket maximum. Medicare Supplement (Medigap) policies can also help cover some of the deductibles, coinsurance, and copayments associated with Original Medicare.