Weight loss surgery is the last option for many people that are overweight or rather considered obese. These individuals have tried other types of weight loss programs and been unsuccessful in reaching the right weight for them. Being overweight is not only about the way a person looks and the quality of living, but it also comes with medical conditions that can be a detriment to the health of the individual. Some of the problems associated with obesity include heart disease, diabetes, high blood pressure, sleep apnea, and digestive issues.
Paying for weight loss surgery can be a challenge for many patients that seek the help. The average cost of bariatric surgery can range from $17,000 to $30,000 depending on the surgery type and the location of the surgical facility. Medicare does cover some weight loss surgery types such as gastric bypass, lap gastric band, and gastric sleeve surgery. There are several requirements that must be met in order for the surgery to be paid for by the healthcare plan. Not only must the patient fit the requirements set by Medicare coverage, but the facility must also be an accredited Bariatric Center of Excellence. You will need to find a Medicare-approved center from the Centers for Medicare and Medicaid Services.
About Medicare
Medicare is a single-payer, national social insurance program that provides health-care coverage for people who are 65 or older, younger people with specific disabilities, and people of any age with End-Stage Renal Disease (ESRD) requiring dialysis or a kidney transplant. Medicare covers some bariatric surgery procedures, like gastric bypass surgery and gastric banding, for morbidly obese patients.
The four different parts of Medicare coverage for specific services:
Medicare Part A (Hospital Insurance)
As the original Medicare, Part A provide benefits and coverage for inpatient hospital stays, care in most skilled nursing facilities, hospice care, and some home health care services.
Medicare Part B (Medical Insurance)
As the original Medicare, Part B benefits include certain doctors’ services, outpatient and preventive care, and medical supplies.
Medicare Part C (Medicare Advantage Plans)
Medicare Part C, known as the Medicare Advantage, is offered by a private company that contracts with Medicare to provide hospital insurance part A and medical insurance part B. Medicare Advantage plans cover most Medicare services and have a yearly out-of-pocket limit. Most Medicare Advantage plans cover prescription medications.
Medicare Part D (Prescription Drug Coverage)
Medicare Part D adds Prescription Drug Plan coverage to original Medicare.
What is Covered?
Gastric Bypass Surgery
Roux-en-Y bypass or gastric bypass is the process of making the stomach smaller and also rerouting the intestines to send food directly to the lower intestine bypassing a large section of intestines. This process provides the patients with a smaller stomach for holding food as well as reducing the number of calories and nutrition the body absorbs from the food due to the short trip through the system.
Gastric Sleeve Surgery
Gastric sleeve surgery is the process of making the stomach smaller and forming it into a small sleeve along the side of the stomach. This process makes the stomach smaller thereby unable to hold as much food as it once did. The process can be accomplished both laparoscopically and with an open surgery.
LAP-BAND Surgery
Adjustable lap band surgery places a band around the stomach making it smaller. The band has inflatable balloons to allow for the adjustment of the band as necessary to reduce the space and opening for the food to go into. This is a reversible procedure and accomplished laparoscopically. The procedure is far less invasive than the others and has less recovery time involved.
These are three procedures that are commonly covered by Medicare. It is important to be sure you are working with a facility that has been approved and to discuss the options with your physician before you get started.
How Much is Covered?
The extent of the Medicare coverage varies depending on the plan that you are involved in. This said, most Medicare base plans cover 80 percent of the amount of the surgery that is considered to be approved by Medicare. The rest may be covered by the MediGap supplement plan and could leave you with no expenses left to pay.
The Process for Surgery Approval
Find a qualified and approved surgeon through the health insurance company or a company such as the American Society of Bariatric Physicians. Confirm that the surgeon you are referred to is accepted by you Medicare by contacting them directly. You can then schedule a time to meet with the surgeon to discuss your options and the fees associated with them.
Ensure that you meet all of the individual health requirements for the surgery as set out by the professional and by the Medicare insurance coverage. The professional and/or your provider will be able to give you additional information on your candidacy for the possible surgery types.
Undergo any special meetings or information sessions that the surgeon might require of you in order to be approved for the surgery. Some ask that you go through an educational process before you begin so that you are aware of the surgery benefits, risks and that you are prepared to make lifestyle changes after the surgery to ensure its effectiveness and success. You may be required to meet with a nutritionist to discuss your approach to food and to teach you how to make nutritious choices after the surgery has been completed.
Go through proper testing such as lab work, x-rays, mental evaluations and physical evaluations by your physician to ensure you are approved to go through the surgery. This approval is vital to be approved by Medicare for your coverage. Your physician can give you the details regarding the entire process and requirements. You will want to remember that there is a reason for each of the tests that you are taking and it is important to try to be patient during the process so that you can get the results you are looking for.
Obtain pre-authorization from Medicare with the help of the physician. The surgeon will need to contact the Medicare authority and supply them with necessary documentation and information to have the surgery approved before it is started in order for the coverage to be there. This process can be lengthy and your surgeon will need to be the one to handle the approval process. You may be asked to answer additional questions by Medicare in order for them to finalize the approval process and pay for the surgery. Patience is an important part of getting through the approval process and it is wise not to give up or get frustrated before the surgery.
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