Medicaid’s Bariatric Surgery Requirements

What are the specific requirements for Medicaid’s bariatric surgery program?

Medicaid coverage for weight loss surgery is decided on a state-by-state basis meaning some states cover it and others do not. Medicaid’s requirements for weight loss surgery are different when compared to other insurances because it is unique in who they cover and how they cover these patients. You will need to meet several requirements to qualify for surgery through Medicaid. You will also need to be free from any medical issues that may prevent you or create a risk for you to have surgery. If you pass these two tests then Medicaid generally will pay for your weight loss surgery.

Criteria for Bariatric Surgery Approval

  • Be over the age of 13 if female or 15 if a male.
  • A body mass index (BMI) over 35 and with one co-morbiditiy including and not limitedto:high blood pressure, high cholesterol, obstructive sleep apnea or diabetes.
  • For patients under the age of 21, a BMI of 40 or more and one co-morbidity is required.
  • Patients must have a printed letter from their primary care physician recommending the necessity of this bariatric procedure.
  • A mental health exam must be passed showing the patient is capable of adopting the necessary lifestyle changes associated with losing the necessary weight.
  • Provide documentation that you have tried and failed using weight on your own.

Complete a medically-supervised program for weight loss for six months (showing proof you have attempted to lose weight within the past 12 months before surgery).

Ultimately some individuals may not qualify for weight loss surgery through Medicaid. These individuals include those with malignant cancer, those with long-term use of steroids, those with chronic pancreatitis, inflammatory bowel disease or who are pregnant or those enduring psychological treatment that could interfere with their new lifestyle.

Bariatric Surgeries that Medicaid Will Cover

When a patient meets the criteria mentioned above, Medicaid will pay for gastric bypass, Lap gastric bands including Lap Band and Realize Band and gastric sleeve surgery.

Other Things to Consider

In order to be covered by Medicaid for your surgery, you must have your weight loss surgery procedure performed at a Center for Excellence (unlike Medicare who recently changed their requirements). These facilities have a level of excellence established that make them successful at administering these life-changing procedures. Medicaid requires that you use one of these centers to guarantee the best treatment.

If you have any questions regarding your Medicaid coverage and whether or not your coverage covers weight loss surgery, contact Medicaid directly. While your surgeon should be a source of information for you and who is responsible for the overall approval, it’s important that you take the time necessary to ensure your surgery is covered so that there are no surprises post-op.