Medicaid’s Requirement for Weight Loss Surgery

Medicaid’s Requirement for Weight Loss Surgery

Medicaid’s requirements for weight loss surgery coverage are a little different as compared to other insurance plans, typically because Medicaid is unique in who they cover and how they cover their patients. You need to meet a number of specific requirements in order to qualify for weight loss surgery through Medicaid, and you also need to be free from any medical issues that would prevent you from having surgery. If you pass these two tests, then Medicaid will generally pay for your weight loss surgery.

Criteria for Surgery Cost Coverage Through Medicaid

In order for Medicaid to completely cover the cost of your surgery as well as the associated visits with your surgeon, you are going to need to meet all of the following criteria.

  • You will need to be over the age of 13 if you’re a female or over the age of 15 if you’re a male.
  • Your Body Mass Index (BMI) must exceed 35 and you must have at least one comorbidity, such as high blood pressure, sleep apnea, high cholesterol or diabetes.
  • If you are below the age of 21, you need to have a Body Mass Index (BMI) exceeding 40 with at least one of the aforementioned comorbidities.
  • You must have a printed letter from your primary care physician recommending the medical necessity of weight loss surgery.
  • You need to pass a mental health exam showing that you are capable of adopting the necessary lifestyle changes for weight loss.
  • You must be able to provide documentation showing that you have tried to manage your weight and comorbidities using standard treatment, but that those attempts were unsuccessful.
  • You must complete a medically supervised program for weight loss spanning 6 months, and you need to show documentation that this weight loss program was attempted within the past 12 months before surgery.

Some people will not qualify for weight loss surgery through Medicaid. If you have any of the following conditions or issues, you will not qualify.

  • Long-term use of steroids,
  • Malignant cancer,
  • Chronic pancreatitis, inflammatory bowel disease or pregnancy,
  • Non-compliance with medical treatments,
  • Psychological treatment that could interfere with your new diet and lifestyle.

Procedures Medicaid Will Cover for Weight Loss

Assuming that you meet all of the criteria mentioned above, Medicaid will pay the coverage for the following weight loss surgery procedures:

  • Gastric bypass procedures,
  • Gastric sleeve surgeries,
  • Lap gastric bands (Lap Band, Realize Band)

Bottom Line and Other Considerations

One of the requirements for Medicaid to pay for your surgery coverage is that you need to have your weight loss surgery done through a Center for Excellence. Bariatric Center for Excellence accreditation is designed to indicate which bariatric surgery centers have achieved a level of excellence when it comes to administering bariatric surgery. Medicaid requires that you visit one of these specific centers to guarantee that you get the best possible treatment.

If you have questions about your Medicaid coverage and whether or not your coverage will pay for weight loss surgery, the best thing to do is to contact the people at Medicaid directly to discuss your coverage. There are many types of surgery that you can undergo for weight loss, but Medicaid only covers the most common ones. If you’re looking to have a different type of weight loss surgery aside from gastric bypass, lap gastric banding or gastric sleeve surgery, then you will need to look for a different type of insurance coverage or you will need to pay out-of-pocket for the procedure.