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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: 
Comorbid Conditions 
 
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). 
Preoperative Psychological/Psychiatric Evaluation 
 
An objective examination by a mental health professional (psychiatrist or psychologist) experienced in the 
evaluation and management of bariatric surgery candidates to exclude patients who are unable to personally 
provide informed consent, who are unable to comply with a reasonable pre- and postoperative regimen, or who 
have a significant risk of postoperative decompensation is recommended. Such evaluation is a Medicare-
covered service. A diagnostic session is appropriate, and treatment sessions are appropriate if the patient has a 
diagnosable disorder that is likely to respond to psychotherapy. The mental health professional, the surgeon and 
the patient should be in agreement that the patient is an appropriate candidate for the surgery. 
 
Patients who have a history of psychiatric or psychological disorder or are currently under the care of a 
psychologist/psychiatrist, or are on psychotropic medications, must undergo preoperative psychological 
evaluation and clearance and the patients record must include documentation of the evaluation and assessment. 
 
Other Preoperative Evaluation 
 
A patient undergoing bariatric surgical procedures should undergo preoperative evaluation that is medically 
reasonable and necessary based upon his comorbid medical conditions and medical/surgical history. All 
underlying medical conditions that will likely impact or complicate the patients surgical and postoperative 
course must be adequately controlled before surgery. Routine preoperative testing (including upper 
gastrointestinal endoscopy) in the absence of signs/symptoms or personal history of a disease that could be 
negatively impacted by anesthesia or surgery is excluded from Medicare coverage by law. 
 
 Postoperative Care 
 
Appropriate postoperative care for the bariatric surgery patient is required for Medicare coverage of bariatric 
surgical procedures. Follow-up must include but not be limited to: 
 Postoperative care by the operating surgeon immediately following surgery and throughout the global 
period for the surgery. 
 At least three follow-up visits with the bariatric surgery team within the first year. 
 Lifetime postoperative care for dietary issues (including vitamin, mineral and nutritional 
supplementation), exercise and lifestyle changes reinforced by counseling and/or support groups 
supervised by a physician knowledgeable in the long-term care of such patients. 
Contraindications to Bariatric Surgery 
 
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. 
Repeat Bariatric Procedures 
 
Repeat bariatric surgery is generally not reasonable and necessary. Medicare does not provide prior 
authorization for these services. Claims for more than one bariatric surgical procedure most likely will create a 
denial. However, in the appeals process, medical documentation may be submitted for review and the service 
may potentially be covered when clinical circumstances demonstrate reasonability and necessity. Appropriate 
ABN and modifiers should be appended to any services potentially to be denied. Refer to IOM Publication 
100-04, Medicare Claims Processing Manual, Chapter 32, Section 15 for more information. 
 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.