Guest post by our friends at Mexico Bariatric.
Weight-loss surgery is one of the most effective tools to fight obesity. Patients lose weight rapidly and keep excess weight off long-term. Within the United States healthcare industry, approval for weight-loss surgery can be difficult because of the eligibility requirements and wait times.
The demand for Medicare coverage for bariatric surgery is growing as the obesity epidemic grows. Medicare’s criteria for coverage is similar to most insurance company requirements. However, Medicare approves surgery on a case-by-case basis.
The bottom line is yes, Medicare covers bariatric surgery. Here’s how!
Medicare is a government-administered national insurance provider that offers health care coverage specifically for individuals that are:
- Over 65 years old
- Under 65 with specific disabilities
- Have End-Stage Renal Disease (ESRD)
What is Weight Loss Surgery?
There are two main components that every weight-loss surgery utilizes:
- Restriction: Restricts the amount of food patients can hold in their stomach. This happens either by reducing the stomach size or removing part of the stomach completely.
- Malabsorption: Changes the anatomy by reducing the caloric intake within the small intestines. This occurs by rerouting or bypassing part of the intestine. Malabsorption prohibits the amount of nutritional value absorbed into the body – both healthy calories and unhealthy calories.
Types of Bariatric Surgery for Medicare
Gastric Bypass Surgery (Roux-n-Y/RNY)
Gastric Bypass Surgery is one of the longest-performed bariatric procedure that Medicare covers in the United States. With Gastric Bypass (RNY), a new stomach is formed (separated from the existing stomach) making a small pouch about the size of a walnut.
This “new” stomach pouch holds about one ounce of food at any given time creating significant restriction. Next, a portion of the small intestines (the duodenum) is bypassed, creating malabsorption. By having both restrictive and malabsorptive components, gastric bypass is highly effective with weight loss averaging about 70% excess weight loss (%EWL) after one year.
LAP-BAND Surgery (Gastric Banding)
The LAP-BAND surgery is a rather basic bariatric procedure that uses only restriction for weight loss. The LAP-BAND procedure works with placing an adjustable gastric band, similar to a thick elastic band, around the upper portion of the stomach to restrict the stomach, ultimately making the upper portion into a small pouch.
The gastric band is not as successful as procedures like gastric sleeve and gastric bypass surgery, with many complications associated. Patients can expect 30-40% excess weight loss after one year.
Gastric Sleeve Surgery (Vertical Sleeve Gastrectomy/VSG)
In Gastric Sleeve Surgery, restriction is the key component of weight loss by completely removing up to 85% of the stomach. The surgeons use a laparoscopic stapler to both cut and staple simultaneously, then completely removing the excess stomach.
The number of gastric sleeve procedures is growing rapidly, as there is no change in patients anatomy. Sleeve patients can expect to lose about 65% excess weight loss after one year.
Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
The Duodenal Switch (DS) is one of the newest bariatric procedures available today. The first part of the DS is the same as the gastric sleeve, although instead of removing 85% of the stomach, patients can expect 70% of the stomach removed.
The Duodenal Switch has the highest reduction of comorbidities although it is rather complicated due to its recent discovery. Surgeons are not as experienced with the DS as with sleeve or bypass, making it harder to find the right hospital and surgeon to perform the procedure. Excess weight loss averages 75% at one year after surgery.
Qualifications for Bariatric Coverage
Only FDA approved bariatric surgery procedures are covered by the Medicare program.
- BMI>35 with one associated comorbidity
- Requires a minimum of 0ne obesity-related comorbidity or health problem (high-cholesterol, diabetes, hypertension)
- Struggled with obesity for past 5 years (with legitimate health records or medical documentation)
Medicare Approval Requirements
After this criterion is met, Medicare covered patients must go through a process before Medicare approval is granted. The requirements are similar to almost all the major insurance provider requirements:
- Records of at least one attempt at a weight loss program that is supervised by a medical expert. Patients must participate fully and actively work towards weight loss within the program. Participants must prove that they had failed at least one program. (Supervised weight loss program – usually provided by the general care provider.)
- A psychological evaluation
- Blood tests for Thyroid, Adrenal, and Pituitary
Bariatric Surgery Approval
To start the approval process, a doctors referral or recommendation is needed by primary care physician. It is critical that you speak with the surgeon to verify that they accept Medicare or Medicare Advantage coverage.
At this point, you will need to verify that the facility/hospital meets the standards of the Centers for Medicare and Medicaid Services (CMS). Be aware that while Medicare Part B will cover 80% of approved surgeries, you are responsible for the Part A and B deductibles and and the 20% Part B coinsurance. If you are covered by a Medigap plan, however, it will help to pay for some or all of these costs, depending on which Medigap plan you chose.
To learn more about Medicare coverage of bariatric surgery under inpatient, outpatient and drug benefits, visit this page about the Parts of Medicare and what they cover.
Part C Medicare Advantage Coverage
With the Medicare Advantage program or Part C, the facility/hospital must be in the same network as your insurance company. Medicare Advantage plans have networks of providers which you must use for your treatment in order to ensure coverage at the lowest out-of-pocket for you. Contact your insurance provider to see your options.
At a minimum, you will generally owe a surgery copay and hospital inpatient stay copay. You can find these costs outlined in your plan’s Summary of Benefits.
Other Alternatives to Medicare: Bariatric Surgery in Mexico
Many patients seeking bariatric surgery cannot pay full price if insurance coverage limits or denies the procedure. An alternative option to Medicare is to have bariatric surgery in Mexico. Not only do you benefit from low costs, you also benefit with quality care with equal safety standards and equipment to surgery in the United States.
Mexico Bariatric Center offers safe and affordable weight loss surgery with effective results. Something we pride ourselves on is our lower complication rate to the United States. In the U.S. complication rates reached 1.4% last year. While Mexico Bariatric Center has a complication rate of only .56% in 2017.
When Medicare won’t cover weight loss surgery, Mexico Bariatric Center is your best affordable solution.
Mexico Bariatric Center is a facilitating company for weight loss surgery in Mexico.