Medicare Guidelines for Lap Band Surgery
Lap band surgery, also known as adjustable gastric banding, involves placing an adjustable band around the stomach to restrict the amount of food you can eat. Medicare pays for this surgery for patients who meet certain requirements.
Eligibility Requirements
You must have a Body Mass Index (BMI) of 35 or above and have at least one weight-related illness like diabetes, hypertension, or sleep apnea. You also must have a documented history of weight loss attempts.
Bariatric Surgery Centers of Excellence
Medicare only pays for the surgery if it is done at a Medicare approved "Center of Excellence" for bariatric surgery. The American Society for Metabolic and Bariatric Surgery designates Centers of Excellence based on outcomes and services provided.
Psychological Evaluation
Medicare requires that patients undergo a psychological evaluation prior to the procedure. A qualified mental health professional must determine that you are mentally stable and emotionally prepared for surgery.
What Medicare Covers
If you have the original Medicare Plan A and B, Medicare covers 80% of the cost of the surgery after you meet your annual deductible. If you have a Medicare Advantage Plan, the amount that is covered depends on your plan. Call the number on your insurance card to inquire.
Pre-Approval
Unlike most health insurance companies, Medicare does not require pre-approval of lap band surgery. If your surgeon determines that you meet the Medicare guidelines, he will perform the surgery and then bill Medicare. If for some reason Medicare then does not pay, you can appeal.
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