Does Medicare Pay for Gastric Sleeve Surgery?

Medicare, a federal health insurance program, primarily serves individuals aged 65 or older, some younger people with disabilities, and those with End-Stage Renal Disease. It covers medical services and procedures, helping beneficiaries manage healthcare expenses. Understanding Medicare’s coverage details is important.

Medicare Coverage for Bariatric Surgery

Medicare covers bariatric surgery, including gastric sleeve, when medically necessary. The Centers for Medicare & Medicaid Services (CMS) sets guidelines for these surgeries, considering them necessary for individuals with obesity-related health conditions. Coverage treats complications from morbid obesity, not solely for weight loss.

To qualify for coverage, individuals must have a diagnosis of morbid obesity, indicated by a body mass index (BMI) of 35 or higher. Beneficiaries must also have at least one obesity-related health condition, or comorbidity, such as type 2 diabetes, heart disease, high blood pressure, or sleep apnea.

Another condition for coverage is a documented history of unsuccessful medical weight loss attempts. Prior supervised efforts through diet, exercise, or behavioral therapy must not have resulted in significant or sustained weight reduction. This ensures surgery is considered after less invasive methods have been explored and proven ineffective.

Specific Criteria for Gastric Sleeve Coverage

Gastric sleeve surgery involves removing a large portion of the stomach. Medicare coverage requires precise medical eligibility. A criterion is a Body Mass Index (BMI) of 35 or higher. If BMI is between 35 and 39.9, the beneficiary must also have at least one obesity-related comorbidity.

Qualifying comorbidities include type 2 diabetes, heart disease, high blood pressure, severe osteoarthritis, and obstructive sleep apnea. For a BMI of 40 or higher, comorbidities are still relevant, though some policies may allow coverage without a specific comorbidity.

A requirement is a documented history of supervised weight loss attempts, typically 6 months to 1 year prior to surgery. Programs must include physician-monitored dietary changes and physical activity. A psychological evaluation is also often required to assess readiness for surgery and ability to adhere to post-operative lifestyle changes.

Navigating the Pre-Approval Process

Once medical eligibility is met, the next step is Medicare’s pre-approval process, or prior authorization. This ensures Medicare covers surgery costs. The physician’s office typically manages documentation submission to Medicare or the Medicare Advantage plan.

Documentation for prior authorization must support medical necessity. It includes medical records, physician notes, pre-operative test results, and documented supervised weight loss attempts. Psychological evaluation results, confirming understanding and commitment to the post-surgical regimen, are also included.

Once documentation is submitted, Medicare or the Medicare Advantage plan reviews it to determine if requirements are met. The review period varies; additional information may be requested if the submission is incomplete. Upon review completion, the beneficiary and provider receive approval or denial. This prior authorization is a critical step before surgery.

Financial Considerations and Medicare Parts

Understanding gastric sleeve surgery’s financial aspects under Medicare involves recognizing how different parts contribute to coverage and potential out-of-pocket costs. Original Medicare (Part A and Part B) provides foundational coverage. Medicare Part A, Hospital Insurance, covers inpatient hospital stays. For inpatient stays, beneficiaries are responsible for a deductible per benefit period, which is $1,676 in 2025.

Medicare Part B, Medical Insurance, covers outpatient services and doctor’s services, including surgeon’s fees, pre-operative consultations, diagnostic tests, and outpatient follow-up care. After meeting the annual Part B deductible ($257 in 2025), beneficiaries typically pay 20% of the Medicare-approved amount for most Part B services. These are the primary out-of-pocket expenses under Original Medicare.

Medicare Part C, Medicare Advantage Plans, are private insurance plans offering Medicare benefits. They must cover at least what Original Medicare covers, including medically necessary gastric sleeve surgery. However, they may have different cost-sharing structures and network restrictions. Medicare Part D, Prescription Drug Coverage, covers necessary medications before and after surgery, with beneficiaries typically paying a deductible and then a coinsurance or copayment. Reviewing specific plan details or contacting the plan administrator is important to understand financial responsibilities.