Does Medicare Cover Sleeve Gastrectomy?

Although weight loss surgery may sound like cosmetic surgery to some, Original Medicare often considers certain weight loss surgery as medically necessary. But what about sleeve gastrectomy?

Many people wonder about this and it leads to the common questions “does Medicare cover sleeve gastrectomy?” In this article, we answer that question in clear, plain English. You will also find what the average costs of sleeve gastrectomy is for those who do not have insurance.

Does Medicare Cover Sleeve Gastrectomy?

The short answer is yes. Medicare will cover the cost of sleeve gastrectomy. 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 sleeve gastrectomy. 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 sleeve gastrectomy. Medicare provides coverage for some weight loss surgeries but not all of them. Among those Original Medicare covers include sleeve gastrectomy.

However, Original Medicare’s coverage for sleeve gastrectomy varies on a regional basis. To know whether it is covered or not, ask your local bariatric surgeon.

Original Medicare provides coverage for your sleeve gastrectomy 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:

BMI of 35 or higher
Tried other ways to treat obesity, but it did not work
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 sleeve gastrectomy

Coverage for sleeve gastrectomy is provided by Medicare Part A if it 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 still provide coverage for your hospital stay after 90 days, but you will have to pay a sizeable copayment per day.

On the other hand, coverage for sleeve gastrectomy 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 sleeve gastrectomy. You will pay for the remaining 20 percent.

Part C and Part D Coverage for Sleeve Gastrectomy

Medicare Advantage plans (Medicare Part C) also provide coverage for sleeve gastrectomy. If Original Medicare covers a treatment or service, then Medicare Advantage plans have to cover them too. But Medicare Advantage plans will also provide coverage for some things that Original Medicare does not. Exactly what that coverage is and how much it costs will vary depending on the specific plan.

Medicare Part D plans provide coverage for medications that you need after sleeve gastrectomy. 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 Sleeve Gastrectomy Cost?

The cost of sleeve gastrectomy ranges from $18,000 to $35,000. This cost will vary depending on the provider and the specifics of your surgery.

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.