Medicare Coverage for Weight Loss

Since 2005, Medicare has been known to pay for weight loss surgery according to several very strict criteria. It is more difficult to receive Medicare coverage for weight loss than for virtually any other kind of illness or ailment.

In order to receive coverage, there has to be a substantial history of weight control problems along with health issues that may be aggravated by being overweight. It can take years to gather enough evidence to undergo Medicare-covered weight loss surgery.

On the other hand, some weight loss treatments may be covered by Medicare on a more routine basis. Be aware that, unless you are going in for surgery, Medicare coverage for weight loss will usually be limited to various forms of counseling.

Under What Conditions Can I Receive Medicare Coverage for Weight Loss?

There are only two scenarios where weight loss coverage is allowed by Medicare:

1) When weight loss is part of the course of treatment for a disease, some costs of weight loss may be covered under your Medicare insurance. There are many diseases where this might be the case. Here are just a few of the most common ones:

  • Hypertension
  • Diabetes
  • Respiratory and cardiovascular failure or related diseases and conditions
  • Hypothalamic lesions
  • Cushing's disease
  • Hypothyroidism (not to be confused with hyperthyroidism, its medical opposite)
  • A variety of others at the discretion of your healthcare professional

All of the above diseases are known to be made worse by weight gain. If you are diagnosed with one or more of these conditions and are determined to be overweight, you may become a candidate for medically supervised weight loss with partial Medicare help.

2) If you are about to undergo surgery, and you are at significantly enhanced risk for complication because of your weight, it is possible to receive Medicare coverage for weight loss. Following your surgery, your weight loss coverage may end unless you meet the standards outlined above.

What Activities Are Covered By Medicare Coverage for Weight Loss?

Your doctor must make a prescription for any weight loss activities that he or she believes are medically necessary. Medicare offers partial coverage, up to 80%, for any of the following activities:

  • An assessment of your current lifestyle in eating and exercise
  • A very limited amount of counseling on both of these topics
  • Diet-related education, along with advice to improve habits
  • Occasional monitoring of your progress through follow-ups

Many people find it difficult to lose weight through this program because of the limitations involved. For example, Medicare will cover only three hours of counseling in the first year, and no more than two hours of counseling in each subsequent year. Furthermore, you must renew your prescription for any services related to weight loss every year. Your doctor will have to update your prescription regularly.

What Other Services Are Included in Medicare Coverage for Weight Loss?

At this time, there are no other covered services pertaining to weight loss unless you require weight loss surgery. Counseling is the only kind of treatment that is available to most Medicare patients except for those who suffer from both of the following:

  • Severe obesity as determined by a common medical scale;
  • Health problems that include at least one related to weight.

If you meet these criteria, then you may qualify for weight loss surgery under Medicare.

What If I Have a Severe Weight Problem?

If you have a severe weight problem, then you may benefit from weight loss surgery. Medicare can cover this surgery under very strict conditions. In order to qualify for a covered surgery, you must be extremely overweight -- holding a Body Mass Index of 35 or more, which is the most common medical measurement of obesity. Body Mass Index measures the amount of fat on your body as compared to weight and build.

If you feel you might benefit from weight loss surgery, it is important to take the first step by consulting with your doctor. He or she will be able to tell you if there is any chance your surgery may be covered by Medicare. This is only possible if you have an existing condition that is worsened by your weight, or if you are a candidate for surgery who must lose weight in order to prevent serious surgical complications.

There are several other requirements that patients must meet before they can have a Medicare covered weight loss surgery. A psychological evaluation is required in advance of the procedure. You may only have your procedure done at a certified Medicare "Center of Excellence" and can only choose from a list of procedures approved by Medicare. All of these can be challenging obstacles to your goal.

However, many patients who receive weight loss surgery are able to lose a substantial amount of weight and can sometimes have a higher likelihood of keeping it off than those who lost the weight through exercise and dieting alone. You should consult your physician to get started on any weight loss plan, since the first step toward weight loss surgery is a documented history of efforts to lose weight.