Does Medicare Cover Bypass Surgery?

Gastric bypass surgery can help people who need to lose a lot of weight that cannot be easily removed. The procedure creates a bypass of the normal functions of the digestive system. This decreases the amount of food a person can eat.

So a common question for those who might get this kind of procedure is, “does Medicare cover bypass surgery?” In this article, we answer that question in clear, plain English. You will also find the average costs of bypass surgery.

Does Medicare Cover Bypass Surgery?

The short answer is yes; Medicare will cover the cost of bypass surgery. But not 100% of the time. As is often the case with Medicare, certain conditions have to be met in order for Medicare to pay for your bypass surgery. Below we look at what these are so you know what to expect.

Original Medicare

Original Medicare (Medicare Part A and Part B) provides coverage for bypass surgery. Medicare provides coverage for some weight loss surgeries but not all of them. Among those Original Medicare covers is bypass surgery.

Original Medicare provides coverage for your bypass surgery if it is considered medically necessary. The operation must also be first ordered by your healthcare provider for Original Medicare to provide coverage. Original Medicare provides coverage for weight loss surgery if the patient has:

A BMI of 35 or higher
Tried other ways to treat obesity, but it did not work
A medical condition caused by their obesity, such as high cholesterol or type 2 diabetes
An order from your healthcare provider stating why you need to undergo bypass surgery

Coverage for bypass surgery is provided by Medicare Part A if your bypass surgery takes place in an inpatient setting. Medicare Part A will cover 100 percent of the costs of hospital stays for up to 60 days. For days 61 to 90, Medicare Part A will still provide coverage. However, you will pay a copayment for each day you are in the hospital. After 90 days, Medicare Part A will no longer provide coverage.

However, Medicare Part A provides 60 lifetime reserve days. If you have them, they will provide coverage for your hospital stay after 90 days. However, there again will be a sizeable copayment per day.

On the other hand, coverage for bypass surgery is provided by Medicare Part B as it often takes place in an outpatient setting. Once approved, Medicare Part B covers 80 percent of the costs of bypass surgery. You will pay for the remaining 20 percent.

Parts C and D Coverage for Bypass Surgery

Medicare Advantage plans (Medicare Part C) also provide coverage for bypass surgery. Part C plans must cover the same things that Original Medicare covers. But these plans will provide coverage for other treatments and services as well. What additional things they provide coverage for and how much the coverage costs depend on the plan.

Medicare Part D plans provide coverage for medications that you need after bypass surgery. Medicare Part D is a prescription drug plan, and just like Medicare Part C, Medicare Part D plans are provided by private insurance companies.

How Much Does Gastric Bypass Surgery Cost?

Gastric bypass surgery may cost somewhere from $18,000 to $35,000. This cost varies depending on the provider.

Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. Always be sure to double check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.