Does Medicare cover gastric band surgery

Obesity is prevalent among seniors in America. According to the Centers for Disease Control and Prevention, as of 2018, nearly 43% of adults 60 or older in America struggle with obesity. There were over 250,000 bariatric surgeries performed in the States in 2018, according to the American Society for Metabolic and Bariatric Surgery. Although a tiny percentage (1.1%) of these surgeries were the gastric band technique, it’s essential to know how Medicare covers this type of surgery.

Gastric band surgery is a type of bariatric surgery that uses a silicone band to shrink the size of your stomach. This band is adjustable and is placed by laparoscopy on the upper section of the stomach. Because the surgery is usually minimally invasive and done in an outpatient setting, you can often return home the same day.

Although Medicare covers gastric band surgery, there are a few requirements you must meet for Medicare to approve your surgery for coverage. If Medicare approves your gastric band surgery, you will have some cost-sharing expenses as well.

Medicare’s requirements for gastric band surgery

Like most insurance carriers, Medicare has specific requirements that you must meet to qualify for gastric band surgery. First, you must meet the preliminary requirements. Then, there are a few other things that must be completed before being approved for surgery.

The preliminary qualifications are as follows:

  • You must have a BMI higher than 35
  • You must have at least two chronic diseases associated with your higher BMI, such as diabetes and high cholesterol.
  • You must have medical records proving that you have struggled with obesity for at least the past five years.

If you meet all three of the above criteria, then you can start the approval process through Medicare. You will have to show proof that you tried a weight loss program to your best ability that was operated by a medical expert. You may also be required to have a psychological evaluation performed, as well as thyroid, pituitary, and adrenal blood tests completed. Once these criteria are met, and you have the necessary tests performed, Medicare will likely cover your gastric band surgery.

How Medicare covers gastric band surgery

If approved, Medicare Part B will cover your gastric band surgery. Since most gastric band surgeries are performed in an outpatient facility, Part B will also cover your stay in the facility. Unless you are admitted as an inpatient for your surgery, Medicare Part A won’t have any part in your coverage for this type of surgery.

Medicare Part B has an annual deductible, which, as of 2020, is $198 per year. You will pay this amount out of pocket before your Part B coverage will kick in. Once you have met your deductible for the year, Part B will cover 80% of your approved Part B services, while you will cover 20%. For example, assuming you’ve already met your deductible for the year if your surgery costs $15,000, then Part B will cover $12,000, and you will pay $3,000.

However, if you have a Medicare plan such as a Medigap or Medicare Advantage plan, your out-of-pocket costs would likely be lower. A Medigap Plan G covers your Part B 20% coinsurance. So, with a Plan G, you’d only be responsible for your Part B deductible.

Medicare Advantage plans are similar to the type of plan you likely had while working. These plans are operated by private insurance carriers. Because each Medicare Advantage plan’s coverage is different, it’s difficult to predict your costs under this type of plan, but it would likely be less than what you would pay if you had Original Medicare.

So, as you can see, Medicare offers substantial coverage for gastric band surgery if it is medically necessary. Talk to your doctor to find out if you meet the requirements for Medicare coverage for this type of bariatric surgery.

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