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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 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 = 35, 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 severe obesity is known to aggravate numerous medical conditions. Comorbid conditions for
which bariatric surgery is covered include the following:

-Type II diabetes mellitus (by American Diabetes Association diagnostic criteria).
-Refractory hypertension (defined as blood pressure of 140 mmHg systolic and/or 90 mmHg diastolic despite
medical treatment with maximal doses of three antihypertensive medications).
-Refractory hyperlipidemia (acceptable levels of lipids unachievable with diet and maximum doses of lipid
lowering medications).
-Obesity-induced cardiomyopathy.
-Clinically significant obstructive sleep apnea.
-Obesity-related hypoventilation.
-Pseudotumor cerebri (documented idiopathic intracerebral hypertension).
-Severe arthropathy of spine and/or weight-bearing joints (when obesity prohibits appropriate surgical
management of joint dysfunction treatable but for the obesity).
-Hepatic steatosis without prior evidence of active inflammation.

Though the conditions listed above need not be immediately life-threatening for Medicare to cover bariatric
surgery, the condition must not be trivial or easily controlled with non-invasive means (such as medication) and
must be of sufficient severity as to pose considerable short- or long-term risk to function and/or survival.
Consideration of the risk-benefit for each individual patient must be used to determine that surgery for obesity
is the best option for treatment for that patient and no contraindications to bariatric surgery may exist.

You can find this rule in Local Coverage Determination (LCD): Bariatric Surgical Management of Morbid
Obesity (L35022) - Effective May 13, 2021.

The rules say that a patient will be deemed to have been unsuccessful with medical treatment of obesity if all of
the following minimal requirements are met per documentation in the medical record:

1. The patient meets BMI requirements stated in national policy (at the time of surgery).
2. The patient has been provided with knowledge and tools needed to achieve such lifelong lifestyle changes,
exhibits understanding of the needed changes and is demonstrated to clinicians involved in his or her care to be
capable and willing to undergo the changes.
3. The patient has made a diligent effort to achieve healthy body weight with such efforts described in the
medical record and certified by the operating surgeon.
4. The patient has failed to maintain a healthy weight despite adequate participation in a structured dietary
program overseen by one of the following:

-Physician (MD or DO).
-Registered dietician (RD).
-Board certified specialist in pediatric nutrition (CSP).
-Board certified specialist in renal nutrition (CSR).
-Fellow of the American Dietetic Association (FADA).

You can find this rule in Local Coverage Determination (LCD): Bariatric Surgical Management of Morbid
Obesity (L35022) - Effective May 13, 2021.

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.