Medicaid Coverage for
Weight Loss
Surgery
Bariatric surgery is
considered medically
necessary when used
as a means to treat
covered medical
conditions that are
caused or
significantly
worsened by the
client’s obesity in
cases where those
comorbid conditions
cannot be adequately
treated by standard
measures unless
significant weight
reduction takes
place. The
pathophysiology of
the covered comorbid
conditions must be
sufficiently severe
that the expected
benefits of weight
loss subsequent to
this surgery
significantly
outweigh the risks
associated with
bariatric surgery.
Bariatric surgery is
not a benefit when
the primary purpose
of the surgery is
any of the
following:
-
For weight loss
for its own
sake.
-
For cosmetic
purposes.
-
For reasons of
psychological
dissatisfaction
with personal
body image.
-
For the
client’s or
provider’s
convenience or
preference.
Bariatric surgery
may be a benefit for
female clients 13
years of age and
older and
menstruating, and
for male clients 15
years of age and
older. All clients
must meet the
criteria outlined in
this article (as
appropriate).
Bariatric surgery
requests for prior
authorization are
considered when the
information
submitted documents
all of the
following:
Note: Clients with
known serious mental
illness must be
assessed prior to
surgery to ascertain
that their illness
is not a
contraindication to
surgery. Clients
must be referred for
appropriate
professional
evaluation any time
the presence of
serious mental
illness is
suspected.
A summary of
treatment and
response.
Documentation must
include a summary of
the treatment
provided for the
client’s comorbid
conditions and a
description of how
the client’s
response to standard
treatment measures
is unsatisfactory.
Medical
necessity.
The documentation
must contain a
description of why
the bariatric
surgery is medically
necessary in the
context of current
treatment and the
medically reasonable
alternatives that
are available.
The name of the
facility in which
the procedure will
be performed.
The facility must be
recognized as a
Bariatric Surgery
Center of
Excellence® (BSCOE)
by CMS as certified
by the American
Society for
Metabolic and
Bariatric Surgery,
or must be
accredited as a
Level 1 bariatric
surgery center as
designated by the
American College of
Surgeons, or must be
a children’s
hospital with an
Adolescent Bariatric
Surgery Program.
Demonstrated
compliance.
The prior
authorization
request must include
documentation that
the client has
demonstrated
compliance with
medical treatment.
The client must also
have demonstrated at
least 6 months of
compliance with a
physician directed,
non-surgical
weight-loss program
within12 months of
the request date.
Pre- and
post-operative
conditions.
Documentation must
include the
following:
-
That the client
is
psychologically
mature and able
to cope with
the
post-surgical
changes.
-
That the
patient and the
parent/guardian
(as applicable)
understand and
will support
the changes in
eating habits
that must
accompany the
surgery and the
extensive
post-operative
follow-up.
-
Adequate
preoperative
nutritional and
psychological
services.
-
How the client
will receive
postoperative
surgical,
nutritional,
and
psychological
services.
Repeat bariatric
surgery may be
considered medically
necessary in either
of the following
circumstances:
-
To correct
complications
from bariatric
surgery such as
band
malfunction,
obstruction or
stricture.
-
To convert to a
Roux-en-Y
gastroenterostomy
or to correct
pouch failure
in an otherwise
compliant
client when the
initial
bariatric
surgery met
medical
necessity
criteria.
Note: Conversion to
a Roux-en-Y
gastroenterostomy
may be considered
medically necessary
for clients who have
not had adequate
success (defined as
a loss of more than
50 percent of excess
body weight) two
years following the
primary bariatric
surgery procedure,
and the client has
been compliant with
a prescribed
nutrition and
exercise program
following the
procedure.
Clients may be
eligible under Texas
Medicaid or the
Comprehensive Care
Program (CCP) for
separate
reimbursement for
nutritional and
psychological
assessment and
counseling
associated with
bariatric surgery.
Behavioral health
services provided as
part of the
preoperative or
postoperative phase
of bariatric surgery
are subject to
behavioral health
guidelines, and are
not considered part
of the bariatric
surgery.