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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 effective for services performed on and after June 27, 2012, Medicare Administrative Contractors (MACs) acting within their respective jurisdictions may determine coverage of stand-alone laparoscopic sleeve gastrectomy (LSG) for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries only when all of the following conditions a.-c. are satisfied.
a. The beneficiary has a body-mass index (BMI) greater than or equal to 35 kg/m2, 
b. The beneficiary has at least one co-morbidity related to obesity, and, 
c. The beneficiary has been previously unsuccessful with medical treatment for obesity.
The determination of coverage for any bariatric surgery procedures that are not specifically identified in an NCD as covered or non-covered. You can find this in the National Coverage Determination (NCD) for Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity (100.1).

The rules say that surgery for severe obesity is a major surgical intervention with a risk of significant early and late morbidity and perioperative mortality. Surgery for severe obesity is not covered in the presence of absolute contraindications, including the following:
- Prohibitive perioperative risk of cardiac complications due to cardiac ischemia or myocardial dysfunction. 
- Severe chronic obstructive airway disease or respiratory dysfunction. 
- Non-compliance with medical treatment of obesity or treatment of other chronic medical condition. 
- Failure to cease tobacco use. 
- Psychological/psychiatric conditions.


o Schizophrenia, borderline personality disorder, suicidal ideation, severe or recurrent depression, or bipolar affective disorders with difficult-to-control manifestations (e.g., history of recurrent lapses in control or recurrent failure to comply with management regimen). 
o Mental retardation that prevents personally provided informed consent or the ability to understand and comply with a reasonable pre- and postoperative regimen. 
o Any other psychological/psychiatric disorder that, in the opinion of a psychologist/psychiatrist, imparts a significant risk of psychological/psychiatric decompensation or interference with the long-term postoperative management.
Note: A history of or presence of mild, uncomplicated and adequately treated depression due to obesity is not normally considered a contraindication to obesity surgery.
- History of significant eating disorders, including anorexia nervosa, bulimia and pica (sand, clay or other abnormal substance). 
- Severe hiatal hernia/gastroesophageal reflux (for purely restrictive procedures such as LAGB).
- Autoimmune and rheumatological disorders (including inflammatory bowel diseases and vasculitides) that will be exacerbated by the presence of intra-abdominal foreign bodies (for LAGB procedure). 
- Hepatic disease with prior documented inflammation, portal hypertension or ascites.

You can find this information in Local Coverage Determination (LCD): Bariatric Surgical Management of Morbid Obesity (L35022).

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.