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Medicaid’s Criteria for Weight Loss Surgery Coverage

Medicaid Covers Weight Loss Surgery

Assuming that you meet the criteria below and that you don’t have any medical issues preventing you from surgery, Medicaid will cover weight loss surgery.

Criteria for Coverage of Surgery Costs

In order for Medicaid to cover the cost of your surgery and the associated surgeon visits, you must meet the requirements below.

  • Over the age of 13 for a female and 15 for a male.
  • Body Mass Index must be over 35 with at least one comorbidity.
    • Co-morbidities include sleep apnea, high blood pressure, high cholesterol, diabetes.
  • If you are under 21, you must have a Body Mass Index (BMI) over 40 with at least one comorbidity.
  • A letter from your primary care physician stating that weight loss surgery is medically necessary.
  • Passes a psychological exam.
  • Documentation showing that the patient tried to manage their comorbidities with standard treatment but they were not successful.
  • The patient must complete and show documentation that he or she participated in a medically supervised weight loss program for 6 months and it happened within the last 12 months prior to surgery.
  • The patient must understand they will be required to change their diet and lifestyle after surgery.
  • Nutritional and psychological services must be available before and after surgery (usually from the physician’s office).

You Might Not Qualify for Weight Loss Surgery Coverage if:

  • Long-term steroid use
  • Malignant cancer
  • Inflammatory bowel disease, chronic pancreatitis, pregnancy, or non-compliance with medical treatment.
  • Psychological treatment that might interfere with post-operative compliance with diet and lifestyle.

Which Procedures Does Medicaid Cover?

Assuming the criteria above are met, Medicaid covers the procedures below.

  • Gastric bypass
  • Lap gastric bands
  • Gastric sleeve surgery

Does Medicaid Require Surgery at a Center for Excellence?

Yes, the facility that you have surgery at must be accredited as a Bariatric Center for Excellence. These facilities have acheived a level of excellence in bariatric surgery.

Medicaid Contact Information

Your state’s Medicaid office can be found here.

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