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, this is because Medicaid is unique in who they cover and how they cover their patients.

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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 Weight Loss 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

What Weight Loss Procedures Will Medicaid Cover?

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

Other Considerations for Medicaid

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.

Related: How to Appeal Insurance Denial for Weight Loss Surgery

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 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.

*Medicaid will not pay for weight loss surgery in Mexico


10 thoughts on “Medicaid’s Requirement for Weight Loss Surgery

  1. My daughter is 18 she is 330 lbs diabetic her doctor has been trying to find a doctor to take medicaid we cant find one we live in sheffield alabama

  2. I’m on medicaid and need help with what I need to do. And where to go first. I’m 52 years old and weigh 264.4 lbs. I’m ready to start the process today. I do take blood pressure medication. When you have time please let me no what I need to do and where to go
    Thank you so much and stay safe.

  3. Hello, my name is Juliette and I have Medicaid with Molina and I would like to know if the weight lost surgery is covered.

  4. The criteria is not very clear BC my BMI is 38, I have high blood pressure, high cholesterol, depression, thyroid issues (on medication for all) and will be getting a sleep study done, and I have United Medicaid BUT when my PC sent my papers to Oshner they declined me bc I never had a stroke and the sleep study results have to be severe for United to cover. I just think the information is misleading and should be more in detail about the criteria.

  5. I had the full gastric in 2009. But the last six months I have gained 49 pounds. I’m out of control. What has happened. Is there surgery for this.

  6. I had the full gastric in 2009. But the last six months I have gained 49 pounds. I’m out of control. What has happened. Is there surgery for this. Do I need a redo

    1. Are you actually willing to put your body through that twice? My guess would be that you need to do better with counting calories and limiting your intake. YOU CAN DO IT!!! I know it is hard, because I struggle too. I haven’t had surgery but I know the feeling of losing weight only to gain it right back. I wish us both much success with our weight loss goals.

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