Gastric sleeve surgery is another term for sleeve gastrectomy. A gastrectomy is defined as the surgical removal of the stomach either in part or in its entirety. Gastric sleeve surgery is an irreversible procedure where the majority, about 75% to 80%, of the stomach is extracted. The surgeon forms the residual portion into a tube resembling a sleeve appended to the small intestine. The Mayo Clinic describes it as “a tube-shaped stomach about the size and shape of a banana.”
The smaller stomach limits the capacity for food containment to approximately two to three ounces in contrast with the average adult stomach capacity of about one quart. In addition to the organ’s reduced magnitude, food intake is reduced for hormonal reasons. Ghrelin, which is the hormone that stimulates appetite, is normally released from the stomach. So, when most of that tissue is removed, the hormone that promotes the feeling of hunger decreases as well.
Medicare Coverage of Bariatric Surgery
Bariatrics is the study of obesity and its treatment. Bariatric surgeries covered by Medicare include gastric bypass and laparoscopic banding surgery, otherwise known as lap band surgery. A laparoscope is a video camera, facilitating a minimally invasive procedure, and it is used in most gastric sleeve surgeries.
The Centers for Medicare & Medicare Services (CMS) published “Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity,” in December 2013. It delineates nationally covered and non-covered surgical treatments for obesity. If you are considering a nationally non-covered procedure, and you are enrolled in a Medicare Advantage or have supplemental insurance, check with your plan administrator for specific coverage details.
Are You Eligible for Medicare Coverage of Bariatric Surgery?
To qualify for Medicare coverage for bariatric surgery, patients must obtain a written medical certification that specific criteria has been met. The document should state that the patient has a Body Mass Index (BMI) of 35 or more, co-morbidity or obesity-related health condition, five-year minimum of suffering from obesity, failed attempt at one or more weight loss programs, positive assessment from a psychological evaluation, and clearance for other diseases that are treatable. Additionally, weight loss may be required prior to surgery to mitigate complications that could be exacerbated by obesity.
Medicare Insurance for Surgical Treatment
To avoid Medicare coverage surprises for any type of surgery, it is a good idea to proactively inquire with the facility about the estimated out-of-pocket costs of the procedure and post-operative care. Also ask about the feasibility and cost impact of an ambulatory surgical center versus the outpatient wing of a hospital as well as inpatient versus outpatient surgery. If you will be admitted to a hospital, confirm your deductible for Medicare Part A. For outpatient care and follow-up office visits, Medicare Part B may help cover the costs of doctor visits and outpatient care. Discuss your concerns and expectations with your physician and family to determine the best course of action for your personal health journey.
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