Does Medicaid Cover Weight Loss Surgery

Getting Medicaid to Pay for Weight Loss Surgery

How can you get Medicaid to pay for weight loss surgery? This is becoming an increasingly common question as more people seek Medicaid coverage for weight loss surgeries and procedures.

The reality is that obesity is a problem in the United States, and it’s known to cause issues such as diabetes, high blood pressure (HBP), and cardiovascular diseases.

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As illustrated below, this is why Medicaid has committed to covering some weight-loss surgeries.

What Is Weight Loss Surgery

Weight loss surgery is a procedure that is done on people who are obese to help them lose weight. Weight loss surgery is used to make changes to your digestive system. See also types of weight loss surgery.

What’s The Process of Weight Loss Surgery Approval by Medicaid

If your state Medicaid covers weight loss surgery, the first step to getting approval for surgery is scheduling a meeting with a doctor.

The approval process begins with a consultation by a healthcare provider specializing in bariatric surgery, including a psychological evaluation, nutritional assessment, and medical necessity documentation, followed by submitting a pre-authorization request to Medicaid with all required documentation.

The entire procedure can take quite some time, so you must be patient.

If Medicaid approves the operation, the doctor will have to confirm your readiness to undergo surgery at the time.

This could mean checking your blood, x-rays, and other surgery preparation procedures.

Determining which part of your operation will be covered by Medicaid in your state is complicated. However, you can confirm with your local state Medicaid office to see whether this information is available.

These procedures are by no means cheap, and you might be wondering if you qualify for this procedure. Medicaid typically takes 4–12 weeks to process a pre-authorization request; delays may occur if documentation is incomplete or additional information is needed.

Read on to learn which bariatric procedures are covered by Medicaid and the criteria used to determine whether to enroll enrollees in weight-loss surgeries.

What are Medicaid’s Criteria for Weight Loss Surgery Coverage

For Medicaid to pay for your bariatric surgery, you must meet the requirements below.

Medicaid requires a BMI of 40 or higher without comorbidities, or a BMI of 35–39.9 with at least one obesity‐related comorbidity (e.g., Type 2 diabetes, hypertension, sleep apnea, or high cholesterol). Some states may have additional BMI criteria for coverage.
Your primary care doctor’s letter indicates that weight loss surgery is necessary.
A psychological evaluation is required to ensure the patient is mentally prepared for the surgery and the necessary lifestyle changes afterward.
Proof showing that you have tried to manage comorbidities with routine treatment but with no success. Comorbidities include sleep apnea, HBP, diabetes, and high cholesterol.
You must prove that you participated in a medically supervised weight loss program for at least six months within the 12 months prior to surgery.
After the weight loss surgery, you must confirm that you will change your routine and diet.
Medicaid requires applicants to be at least 13 years old for females and 15 years old for males; for individuals under 21, stricter BMI and comorbidity requirements apply.
Medicaid requires medical records showing obesity‐related conditions and prior weight loss attempts, a psychological evaluation report, a nutritional assessment report, and a pre-authorization request that includes CPT/ICD codes and support letters from healthcare professionals.

What Can Disqualify You From Medicaid’s Weight Loss Surgery Coverage

Noncompliance includes failure to complete a medically supervised weight loss program (typically 6–12 months), lack of documented prior weight loss attempts, and failure to follow pre-surgical dietary and medical guidelines.
Conditions such as pregnancy, active cancer, chronic steroid use, chronic pancreatitis, or inflammatory bowel disease, and severe cardiopulmonary conditions may disqualify you from Medicaid coverage for weight loss surgery.
Psychological disqualifications include untreated mental health conditions (e.g., severe depression, anxiety, eating disorders), active substance abuse, and cognitive impairments that hinder adherence to post-surgical care plans.
Cancer.
Long-term steroid usage.

Which Other Medicaid Considerations Are Required

For Medicaid to cover your bariatric surgery, it generally needs to be performed at a facility accredited as a Bariatric Center of Excellence or that meets other defined quality standards. This certification is meant to show you which hospitals have been deemed fit for weight loss surgeries by Medicaid.

Medicaid often requires surgeries to be performed at MBSAQIP-accredited facilities, which ensure multidisciplinary care, participation in outcome registries, compliance with volume standards, and continuous quality improvement; some states also accept Joint Commission or Blue Distinction Center designations. There are various kinds of operations that you can undergo to lose weight, but Medicaid only covers the most common types.

Medicaid covers gastric bypass, gastric sleeve, and lap band surgeries, while coverage for duodenal switch surgery is less common and depends on state-specific policies, depending on state-specific policies, subject to approval on a case-by-case basis.

Which Weight Loss Surgeries Does Medicaid Cover

Gastric Bypass

Gastric bypass is a type of weight loss surgery during which a surgeon operates on your gut and small intestines to change how they digest and absorb food.

Gastric bypass enables weight loss by:

Restricting the amount of food that your gut can hold
Limiting the number of nutrients and calories absorbed by your small intestine
Transforming your gastrointestinal hormones, which help to suppress your appetite and make you feel fuller for longer

Lap Band Revision

Lap band revision is a bariatric procedure that involves installing an adjustable silicone band on your stomach to create a small gut section above the band. The rest of the gut remains below the band, which limits the quantity of food or beverages you can eat or drink in one sitting.

The band is adjustable, and the procedure is reversible. Lap band revision is done laparoscopically, and it’s not as intrusive as other gut procedures.

Gastric Sleeve

Vertical gastrectomy, or gastric sleeve, is a weight loss surgery that removes approximately 75-80% of the stomach. It is one of the most common bariatric procedures in the United States.

Medicaid coverage and out-of-pocket costs vary by state program and individual circumstances. There are some things you need to pay for, such as

Co-payments – You pay a fixed sum when you receive specific checkups. For Medicaid, this typically applies to prescription medicine.
Deductibles – This is the yearly sum that you pay for a specific timeframe before an insurer starts to cover all your checkups and procedures
Co-insurance – This is a chunk of the treatment cost you must pay alone.

Final Thought

Medicaid’s requirements for bariatric procedures or weight loss surgery coverage differ slightly from those of other insurance providers in the US.

Coverage for bariatric surgery varies by state Medicaid program, with some states not covering it. Pre-approval requirements and covered procedures may vary by state Medicaid program As illustrated above, many qualifications are needed for Medicaid to approve and cover your surgery.

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Does Medicaid Cover Weight Loss Surgery