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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Roux-en-Y Gastric Bypass (RYGBP) achieves weight loss by gastric restriction and malabsorption. Reduction of the stomach to a small gastric pouch (30 cc) results in feelings of satiety following even small meals. This small pouch is connected to a segment of the jejunum, bypassing the duodenum and very proximal small intestine, thereby reducing absorption. RYGBP procedures can be open or laparoscopic. You can find this rule in National Coverage Determination (NCD) for Bariatric Surgery for Treatment of Morbid Obesity (100.1) - Effective February 12, 2009. The rules say that effective for services performed on and after February 21, 2006, Open and laparoscopic Roux-en-Y gastric bypass (RYGBP), open and laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS), and laparoscopic adjustable gastric banding (LAGB) are covered for Medicare beneficiaries who have a body-mass index of 35 or more, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. These procedures are only covered when performed at facilities that are: (1) certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center (program standards and requirements in effect on February 15, 2006); or (2) certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (program standards and requirements in effect on February 15, 2006). You can find this rule in National Coverage Determination (NCD) for Bariatric Surgery for Treatment of Morbid Obesity (100.1) - Effective February 12, 2009. The rules say that the following, based on national guidelines for bariatric care, are the minimum specifications to be documented in the patient record in order to demonstrate the beneficiary has been previously unsuccessful with medical treatment for obesity as required by the NCD: 1. The beneficiary has been previously unsuccessful with medical treatments for obesity. The latter includes but is not limited to: active participation within the last 12 months prior to bariatric surgery in a weight-management program that is supervised by a physician or other health care professionals for a minimum of four consecutive months. The weight-management program must include monthly documentation of patient's weight and BMI, current dietary regimen and physical activity (e.g. exercise program). 2. Physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement. 3. A thorough multidisciplinary evaluation is required within the previous six months which includes ALL of the following: a. an evaluation by a bariatric surgeon recommending surgical treatment, including a description of the proposed procedure(s) b. a separate medical evaluation from a physician other than a surgeon and preferably the beneficiary's primary care physician that includes both a recommendation for bariatric surgery as well as a medical clearance for the proposed bariatric surgery c. mental health and psychosocial clearance for bariatric surgery by a mental health provider including a statement regarding motivation and ability to follow post-surgical requirements d. a nutritional evaluation by a physician or registered dietician. You can find this rule in Local Coverage Article: Billing and Coding: Bariatric Surgery Coverage (A53028) - Effective October 1, 2018.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.