Health

Will Medicare Cover a Gastric Band?

According to the Centers for Disease Control and Prevention (CDC), nearly 43% of adults 60 or older were obese in 2018. Bariatric surgery is one of the many options for treating obesity. The most common forms of bariatric surgery include gastric bypass, gastric sleeve, and gastric band. 

What is gastric band surgery?

Gastric band surgery treats obesity by tricking the stomach into thinking it’s full. To do this, an adjustable band is placed around the stomach with a laparoscope to create a smaller stomach pouch. With a smaller stomach, your hunger is satisfied with smaller amounts of food. Over time, the gastric band can be adjusted, making the stomach pouch even smaller.

Because hunger is satisfied with less food when the band is in place, your overall calorie intake is lower, which helps you lose weight. 

Some advantages to gastric band surgery include:

  • Weight loss of as much as 40 – 50%
  • No long hospital stays and recovery periods because it’s typically an outpatient procedure
  • The surgery can be reversed
  • Lowest rate of complications out of all bariatric surgeries

Some disadvantages to gastric band surgery include:

  • Weight loss is slower than other bariatric surgery options
  • Requires a foreign object to be placed in the body
  • Potential mechanical issues with the band
  • Has a higher rate of reoperation than other bariatric surgery options

Will Medicare cover gastric band surgery?

Medicare covers gastric band surgery if you meet the requirements for medical necessity. Because gastric band surgery is often done as an outpatient procedure, Medicare Part B typically pays.  If approved by Medicare, your surgery will be covered at 80%. 

The first Medicare requirement for gastric band surgery is a body mass index of at least 35. The second requirement is that you must be diagnosed with at least one health condition related to your obesity. Examples include: 

  • Cardiomyopathy
  • Hepatic steatosis (without active inflammation)
  • Hyperlipidemia
  • Hypertension
  • Obstructive sleep apnea
  • Pseudotumor cerebri
  • Severe arthropathy of the spine and/or weight-bearing joints
  • Type II diabetes

In addition to these requirements, your medical records must also show unsuccessful attempts to treat obesity, such as failed diet attempts. You also must pass a psychological evaluation. 

How much does gastric band surgery cost under Medicare?

As mentioned above, if Medicare approves your surgery, Part B will cover 80% of the Medicare-approved costs. This includes any medically necessary services needed before and after the surgery, such as lab work and follow up doctor visits. You are responsible for the Part B deductible and 20% of the Medicare-approved costs. 

However, a Medigap plan or Medicare Advantage plan could lower your out-of-pocket spending. Medigap plans pay after Part A and Part B have approved a service. Most Medigap plans cover your 20% Part B coinsurance in full. For example, if you have a Medigap Plan G and your gastric band surgery is approved by Medicare, your out-of-pocket costs would be limited to the Part B deductible, which as of 2021 is $203. 

Medicare Advantage plans pay instead of Part A and Part B, meaning your plan provider will set your cost-sharing, not Part B. For example, instead of paying a 20% coinsurance, you may pay a $300 copay for your surgery and a $20 copay for your lab work. However, costs vary by plan, doctor, and hospital.

Obesity screenings and counseling

Medicare Part B also covers obesity screenings if your BMI is at least 30. During your screening, you may also receive behavioral counseling to help you lose weight naturally. Your doctor may assess your diet and exercise routine and make adjustments to help you lose weight.

Medicare covers gastric band surgery as long as you meet the requirements, and your doctor determines it is the best option for you.

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