Medicare Coverage for Bariatric Surgery in the State of Texas

Weight loss surgery for Medicare recipients is considered higher risk because often times patients are disabled secondary to their weight and related conditions OR are over the age of 65.  Dr. Patel believes that weight loss surgery for Medicare recipients should be done at specialized centers.  This belief is shared by many other academic centers.

Dr. Patel, in partnership with Southwest General Hospital, have proudly created a bariatric surgery center which caters to Medicare recipients throughout South Texas.  Together the center represents one of the few programs in Texas that is dedicated to the treatment of Medicare patients.  The team assembled at Southwest General Hospital includes a variety of specialists including nephrology, cardiology, pulmonary critical care and endocrinology.

I Have Medicare, am I Eligible for Weight Loss Surgery?

Medicare coverage guidelines in the state of Texas DO NOT follow traditional CMS requirements.  Sadly, the requirements for patients that do not have Medicare replacement plans are much stricter in the state of Texas.  This is due to a local care determination set forth by Novitas, the default administrator for the state of Texas.  The requirements under this local care determination are as follows:

  • Have a BMI of 35 or greater AND:
    • At least one weight-related medical condition defined as follows:
      • Type 2 diabetes.
      • Severe obstructive sleep apnea.
      • Refractory hypertension (high blood pressure) which does not respond to a maximum dose of three medications
      • Refractory elevated cholesterol which does not respond to two medications
      • Need for joint or spine surgery which cannot be done unless you lose 100lbs or more (this must be documented by an orthopedic or spine surgeon)

For more information about these requirements, please refer to the Medicare Requirements for the State of Texas.

How Do I Know Who My Administrator Is?

If the only Medicare card you have is the traditional red, white, and blue card, in all likelihood Novitas is your administrator.  If you have signed up for a Medicare Replacement such as

  • Humana Gold
  • Aetna Medicare
  • United Healthcare Medicare
  • PHC

These respective companies follow traditional CMS requirements set forth by the National Care Determination.  Under these requirements, you must have a BMI greater than 35 with a condition such as diabetes, high blood pressure, sleep apnea or high cholesterol.

You will be assigned an insurance advocate who will guide you through the process of getting to surgery and help you understand your Medicare benefits. Dr. Patel and his team at TBS are confident in working with all Medicare patients and helping with their insurance criteria.

 

Am I Too Old for Weight Loss Surgery?

As a Medicare patient, you have the right to be appropriately screened to determine if your individual risks outweigh the benefits of weight loss surgery, but in general the benefits truly outweigh the risks.

Dr. Patel is an expert at reviewing every patient’s medical and past surgical history to determine if weight loss surgery would benefit you.  An extra set of evaluation tests are ordered for seniors in order to correctly decide if weight loss surgery would benefit you.  These tests include:

  • Cardiac Stress Test
  • Chest X-Rays
  • Occasionally a Pulmonary Evaluation

Risks vs. Benefits of Weight Loss Surgery for Seniors

The benefits of weight loss surgery for patients over 65 is well documented, enforced by the decision of Medicare to provide coverage for bariatric procedures.  Researchers found that adults over 65 will notice the same improvements in quality of life from weight loss surgery that patients in their thirties and forties have. Older adults will also experience a decrease in obesity related medical conditions such as type 2 diabetes or high blood pressure, helping to lower or end the cost of prescriptions, following their weight loss surgery.

At TBS, we truly believe age is just a number and there are significant health benefits for a patient of advanced age.  The improvements in medical conditions from weight loss surgery allow seniors to enjoy a better quality of life and hopefully an overall quantity of life.

“The surgery pays for itself in the health benefits.” – James Yeamans, 68, Medicare patient. 
Read James’ full weight loss success story HERE.