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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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say 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. Refer to 
IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 150, for more information 
on co-morbid conditions related to morbid obesity. 
 
Previous Unsuccessful Medical Treatment for Obesity 
 
With or without bariatric surgery, successful obesity management requires adoption and lifelong practice of 
healthy eating and physical exercise (i.e., lifestyle modification) by the obese patient. Without adequate patient 
motivation and/or skills needed to make such lifestyle modifications, the benefit of bariatric surgical 
procedures is severely jeopardized and not medically reasonable or necessary. Patients considering bariatric 
surgical options must have been provided with knowledge and tools needed to achieve such lifelong lifestyle 
changes and must be capable and willing to undergo the changes. 
 
For the purposes of this LCD, 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: 
 The patient meets BMI requirements stated in national policy (at the time of surgery). 
 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. 
 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. 
 The patient has failed to maintain a healthy weight despite adequate participation in a structured dietary 
program overseen by one of the following: 
o Physician (MD or DO). 
o Registered dietician (RD). 
o Board certified specialist in pediatric nutrition (CSP). 
o Board certified specialist in renal nutrition (CSR). o Fellow of the American Dietetic Association (FADA). 
You can find this rule at the Medicare Local Coverage Determination (LCD) L35022: Bariatric Surgical 
Management of 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.