Medicare is a government-run health insurance program that provides coverage for seniors and people with disabilities. It can be difficult to determine whether or not Medicare covers gastric bypass surgery, as the answer changes depending on your specific situation. In this blog post, we will discuss Medicare’s coverage of gastric bypass surgery and help you figure out if it is a viable option for you.
Kicking Things Off
If you are considering gastric bypass surgery, the first step is to consult with a doctor to see if it is medically necessary. You will need to find a doctor that accepts Medicare and schedule a consultation. If your doctor determines that gastric bypass surgery is necessary, they will need to submit a request for coverage to Medicare. Medicare will then review the request and make a determination based on their criteria.
Learn about the long-term success rate of gastric bypass surgery.
What Criteria Must Be Met to Qualify for Medicare Gastric Bypass Coverage
In general, Medicare will only cover gastric bypass surgery if it is considered medically necessary. This means that the surgery must be performed in order to treat a specific medical condition and not simply for cosmetic purposes. Gastric bypass surgery is usually only covered for people who:
- Have a body mass index (BMI) of 40 or higher, or a BMI of 35 or higher with one or more obesity-related conditions.
- Have tried other weight loss methods, such as diet and exercise, without success.
- Are unable to participate in other weight loss programs due to a medical condition.
- Have at least one weight-related comorbidity. Some examples include gallbladder disease, heart disease, high blood pressure, and sleep apnea.
If you do not meet the above criteria, Medicare is unlikely to cover your gastric bypass surgery.
Which Parts of Medicare Cover Gastric Bypass Surgery?
Original Medicare (parts A and B) covers gastric bypass surgeries. Part A covers inpatient hospital stays, while Part B covers outpatient procedures. Medicare Advantage plans (Part C) also cover gastric bypass surgery in limited cases. If you have a Medicare Advantage plan, check with your insurance provider to see what coverage is available to you.
What If Medicare Denies Coverage?
If Medicare denies coverage for your gastric bypass surgery, you have the option to appeal the decision. You will need to submit a written appeal within 180 days of the denial. Keep in mind that appeals can be time-consuming, so it is important to act quickly if you decide to take this route.
Also read this blog to understand the difference between Mini Gastric Bypass vs Gastric Bypass.