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Weight Loss Surgery Covered by Medicare and Private Health Insurance

We are often asked if weight loss surgery is covered by Medicare and private health insurance. The short answer is, yes bariatric surgery is covered by Medicare and most private health insurers.

Patients covered by Medicare are entitled to subsidised medical services for bariatric surgery, provided they meet the medical criteria requirements.

Under the current Medicare Medical Benefits Scheme (MBS) weight loss surgery or, Bariatric Procedures are related to Items 31569 to 31581, and anaesthesia item 20791.

Items 31569 to 31581 and item 20791 provide for surgical treatment of clinically severe obesity and the accompanying anaesthesia service (or similar).

Private insurance may cover weight loss surgery and programs, but it’s important to check directly with your insurer. Individual private insurers can have differing terms and conditions for weight loss surgery.

The Types of weight-loss surgery Medicare and private health insurance may cover

Dr Lockie performs both gastric sleeve and gastric bypass surgery, which are both covered by Medicare and most private health insurers, for patients who meet the criteria.

Laparoscopic Sleeve Gastrectomy (gastric sleeve)

Gastric sleeve surgery removes 70 to 80 per cent of the stomach, turning the stomach from a spacious bag to a small tube. There is no foreign device left in the body and there is no significant alteration to the gastrointestinal tract.

This operation is a good option for obese patients. It is a good volume control option, and this is often an issue for men in particular.

It may not be the best option of you have any significant reflux.

Laparoscopic Gastric Bypass

Another common type of weight loss surgery, the laparoscopic gastric bypass. The Roux-en-Y gastric bypass (RYGB) has been around for 40 yrs, and is still the operation that all other operations are compared to. RYGB can result in a 65 to 75 per cent reduction in excess weight. It involves the creation of a small pouch from the upper part of the stomach. The rest of the stomach is disconnected and left inside.

A loop of the small bowel is then brought up and attached to the new stomach pouch. Another join is made lower down on this loop to connect the food to the rest of the small bowel. When patients eat, the food goes through the small pouch and into the loop of the small bowel but does not meet the digestive juices for around 100cm.

This type of surgery is considered the best option for Type 2 or non-insulin dependent diabetics, the super obese (BMI>50), sweet eaters, emotional eaters and patients with significant reflux.

A fixed ring can be added to the gastric bypass. This is done in super obese patients and often in revisional surgery.

How much is the Medicare rebate?

Medicare will provide reimbursement for the procedures indicated by the item codes, although individuals may still need to rely on private insurance to meet the remainder of the cost. Here, a set rate is applied for each surgery.

Private health insurance for weight loss surgery

The amount of cover a private insurance company provides for weight-loss surgery typically ranges between $1,700-$5,300, after the Medicare rebate.

Without private insurance patients may be forced to pay around $12,000-$18,000, even after the Medicare rebate. With the support of private health insurance, this drops to about $2,800 - $7,000.

Costs will also vary depending on the surgery recommended for each patient.

Free bariatric surgery consultation is available

Book in for your free, no-obligation consultation with our Perioperative Nurse, Surgical Assistant, Shirley Lockie. In this consultation you will be provided with information on the different types of surgeries, program appointments and we will answer any questions you may have about the process. Shirley will also help guide you on Medicare cover and how to navigate your private health insurance options.

Contact us on 07 3355 2011 or schedule a consultation here.

Medical criteria for bariatric surgery

To undergo weight loss surgery covered by Medicare and private health insurance, patients need to meet certain medical criteria.

Does BMI matter?

BMI is one of the most important considerations. This measures body composition based on height and weight.

According to the Medicare MBS, the term clinically severe obesity generally refers to a patient with a Body Mass Index (BMI) of 40 or more, or a patient with a BMI of 35 or more with other major medical co-morbidities or obesity related disease.

Obesity-related diseases include:

  • Heart disease
  • Obesity
  • Asthma
  • Sleep apnoea
  • Osteoarthritis

It’s important to note the BMI values in different population groups may vary due, in part, to different body proportions which affect the percentage of body fat and body fat distribution. Consequently, different ethnic groups may experience major health risks at a BMI that is below the 35-40 provided for in the definition.

These guidelines were set out when surgery was performed as an open operation, whereas surgery is now all key-hole. The MBS states the decision to undertake obesity surgery remains a matter for the clinical judgment of the surgeon.

Therefore, I will consider individual patients with a BMI>32 for bariatric surgery, with or without an obesity related disease.

Factors that determine the cost of weight-loss surgery

The cost of bariatric surgery depends on several factors. These include:

  • Surgeon consultation fees
  • Type of surgery chosen
  • Surgeon fees
  • Surgical assistant fees
  • Hospital fees
  • Anaesthetist’s fees
  • Medications prescribed after surgery
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