Does Medicaid pay for bariatric surgery?

A fellow caregiver asked...

Does medicaid pay for bariatric surgery and if so which ones?

Expert Answer

Each state runs its own Medicaid program, with separate rules and procedures, under the umbrella of a national Medicaid program. In general, Medicaid programs cover bariatric surgeries for some patients under circumstances that are very close to the rules set up by Medicare for its coverage of these surgeries. The Medicare rules include the following:

(1) The patient must be "morbidly obese," meaning a body mass index (BMI) of 35 or higher. (2) The patient must also have at least one specific serious medical condition in addition to and related to obesity (such as type-2 diabetes, coronary artery disease, hypertension, osteoarthritis, and certain others). (3) The patient must have had repeated failures to lose weight in non-surgical, medically-supervised weight loss programs (including diet and exercise programs, counseling, and drug therapy) (4) Other additional therapies have been determined inappropriate by the treating specialist physician. (5) The patient undergoes a psychological evaluation, which determines that the surgery is psychologically appropriate.

If you meet all those conditions, and your treating doctor prescribes such surgery, Medicare (and most Medicaid programs) will cover only four specific types of procedures: gastric bypass; open and laparoscopic Roux-en-Y gastric bypass; laparoscopic adjustable gastric banding; and open and laparoscopic biliopancreatic diversion with duodenal switch.

To receive Medicare coverage, the surgery must be performed in what is called a Medicare-approved "Center of Excellence," which is a high-volume center which specializes in these types of surgeries. To find out more details about the conditions under which Medicare covers bariatric surgeries, see Medicare's official National Coverage Determination (NCD) for bariatric surgery for Treatment of Morbid Obesity (100.1).

Given all these rules, obtaining Medicaid coverage of bariatric surgery requires the close cooperation of the doctor who is treating you for your obesity.