Will Medicare Cover Gastric Band Surgery?

Obesity is a leading health concern among Americans. According to the Centers for Disease Control and Preventive (CDC), nearly 43% of adults 60 or older in America are obese. Obesity is determined by your body mass index (BMI), which is based on your height and weight. You are considered obese if your body mass index (BMI) is 30 or more. 

Obese adults are more likely to develop certain serious health conditions than adults of normal weight. These health conditions can include diabetes, heart disease, hypertension, sleep apnea, and arthritis. 

If you’re overweight, you may have considered weight loss surgery. But how do you know which is right for you? And you may wonder, “Will Medicare cover my weight loss surgery?” If this sounds like you, continue reading. 

Types of weight loss surgery

There are several types of weight loss surgery, and your doctor may recommend one based on your situation. Some of the most common weight loss surgeries are gastric bypass, gastric band, gastric sleeve, and biliopancreatic diversion with duodenal switch. However, there are two main techniques used in each type of surgery – restriction and malabsorption. 

Restriction simply reduces the size of your stomach, so you feel full faster. This is usually done with a gastric band. Malabsorption is achieved by bypassing part of your intestine so fewer calories, both healthy and unhealthy, are absorbed into your body. 

Gastric band surgery, commonly known as lap-band surgery, is one of the most common types of weight loss surgery because it’s minimally invasive and performed as an outpatient procedure. However, not everyone qualifies for Medicare-covered gastric band surgery.

How Medicare covers gastric band surgery

Medicare generally covers medical services and procedures proven to be medically necessary to treat or diagnose a health condition. Bariatric surgery, such as gastric band surgery, is covered by Medicare, but only under certain conditions.

For Medicare to cover your gastric band surgery, you must have:

  • a BMI of at least 35
  • at least one serious condition related to obesity
  • been obese for the past five years
  • participated in a supervised weight loss program without success
  • a recommendation for the surgery from your doctor
  • passed a psychological evaluation
  • had all other possible causes for your obesity ruled out by a doctor

If you don’t meet all of these requirements, Medicare will likely not cover your surgery. For example, suppose you’re technically obese with a BMI of 30. In that case, Medicare won’t cover your surgery, or if you have a BMI of 35 but have no other obesity-related conditions, Medicare won’t cover your surgery.

Medicare costs for gastric band surgery

Costs for gastric band surgery under Medicare depend on numerous factors, such as the type of Medicare plan you have and the doctor and hospital you use While it’s hard to calculate the exact dollar amount you’ll owe, you can calculate your deductible, coinsurance, and other related costs. 

For example, if you have Part A and Part B, and your surgery is done as an outpatient procedure, you will be responsible for your Part B deductible and 20% coinsurance. If you see a doctor who doesn’t accept Medicare assignment, you will also be responsible for up to 15% in excess charges.

However, if you have a Medigap plan, depending on the plan, your costs will likely be less. For example, if you have Original Medicare (Part A and Part B) plus a Medigap Plan G, you can expect only to be responsible for the Part B deductible, which as of 2020, is $198.

If you receive your coverage through a Medicare Advantage plan instead, your cost will depend on your specific plan’s deductible, coinsurance, and copays.

Obesity screening and counseling

Medicare will also cover intensive behavioral therapy (IBT) for obese beneficiaries. The therapy sessions may include a dietary assessment as well as a diet and exercise plan to help you lose weight. If your doctor accepts Medicare assignment and the therapy is held in a primary care setting.

If you’re dealing with obesity, consider adjusting your diet and exercise routine. If you’re able to lose weight naturally, then you’ll save yourself downtime and money. However, if you’ve tried it all, consider talking to your doctor about gastric band surgery.