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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 state that obesity may be caused by medical conditions such as hypothyroidism, Cushing's disease, 
and hypothalamic lesions, or can aggravate a number of cardiac and respiratory diseases as well as diabetes and 
hypertension. Non-surgical services in connection with the treatment of obesity are covered when such services 
are an integral and necessary part of a course of treatment for one of these medical conditions. 
In addition, supplemented fasting is a type of very low-calorie weight reduction regimen used to achieve rapid 
weight loss. The reduced calorie intake is supplemented by a mixture of protein, carbohydrates, vitamins, and 
minerals. Serious questions exist about the safety of prolonged adherence for 2 months or more to a very low-
calorie weight reduction regimen as a general treatment for obesity, because of instances of cardiopathology 
and sudden death, as well as possible loss of body protein. 
 
Bariatric surgery procedures are performed to treat comorbid conditions associated with morbid obesity. Two 
types of surgical procedures are employed. Malabsorptive procedures divert food from the stomach to a lower 
part of the digestive tract where the normal mixing of digestive fluids and absorption of nutrients cannot occur. 
Restrictive procedures restrict the size of the stomach and decrease intake. Surgery can combine both types of 
procedures. 
 
The following are descriptions of bariatric surgery procedures: 
1. Roux-en-Y Gastric Bypass (RYGBP) 
The 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. 
2. Biliopancreatic Diversion with Duodenal Switch (BPD/DS) or Gastric Reduction Duodenal Switch 
(BPD/GRDS) 
The BPD achieves weight loss by gastric restriction and malabsorption. The stomach is partially resected, but 
the remaining capacity is generous compared to that achieved with RYGBP. As such, patients eat relatively 
normal-sized meals and do not need to restrict intake radically, since the most proximal areas of the small 
intestine (i.e., the duodenum and jejunum) are bypassed, and substantial malabsorption occurs. The partial 
BPD/DS or BPD/GRDS is a variant of the BPD procedure. It involves resection of the greater curvature of the 
stomach, preservation of the pyloric sphincter, and transection of the duodenum above the ampulla of Vater 
with a duodeno-ileal anastomosis and a lower ileo-ileal anastomosis. BPD/DS or BPD/GRDS procedures can 
be open or laparoscopic. 
 3. Adjustable Gastric Banding (AGB) 
The AGB achieves weight loss by gastric restriction only. A band creating a gastric pouch with a capacity of 
approximately 15 to 30 cc's encircles the uppermost portion of the stomach. The band is an inflatable 
doughnut-shaped balloon, the diameter of which can be adjusted in the clinic by adding or removing saline via 
a port that is positioned beneath the skin. The bands are adjustable, allowing the size of the gastric outlet to be 
modified as needed, depending on the rate of a patient's weight loss. AGB procedures are laparoscopic only. 
4. Sleeve Gastrectomy 
Sleeve gastrectomy is a 70%-80% greater curvature gastrectomy (sleeve resection of the stomach) with 
continuity of the gastric lesser curve being maintained while simultaneously reducing stomach volume. In the 
past, sleeve gastrectomy was the first step in a two-stage procedure when performing RYGBP, but more 
recently has been offered as a stand-alone surgery. Sleeve gastrectomy procedures can be open or laparoscopic. 
5. Vertical Gastric Banding (VGB) 
The VGB achieves weight loss by gastric restriction only. The upper part of the stomach is stapled, creating a 
narrow gastric inlet or pouch that remains connected with the remainder of the stomach. In addition, a non-
adjustable band is placed around this new inlet in an attempt to prevent future enlargement of the stoma 
(opening). As a result, patients experience a sense of fullness after eating small meals. Weight loss from this 
procedure results entirely from eating less. VGB procedures are essentially no longer performed. 
 
You can find this rule in the Medicare National Coverage Determination (NCD)-100.1-Bariatric Surgery for 
Treatment of Co-Morbid Conditions Related to Morbid Obesity. 
 
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.