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:

• No significant contraindications. The same contraindicates exist for bariatric surgery as for any other elective abdominal surgery. Documentation provided for prior authorization must attest that none of the following additional contraindications exist:

  • Endocrine cause for obesity, inflammatory bowel disease, chronic pancreatitis, cirrhosis, portal hypertension, or abnormalities of the gastrointestinal tract.

  • Chronic, long term steroid treatment.

  • Pregnant, or plans to become pregnant within 18 months.

  • Non-compliance with medical treatment.

  • Significant psychological disorders that would be exacerbated or interfere with the long-term management of the client after the operation.

  • Active malignancy.

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.

• Client eligibility. Bariatric surgery may be prior authorized when the client meets all of the following criteria:

  • The client is a female at least 13 years of age and menstruating, or a male at least 15 years of age. Clients 20 years of age and younger must also have reached a Tanner stage IV plus 95 percent of adult height based on bone age, and must have a body mass index (BMI) of greater than or equal to 40 kg/m2. Clients 21 years of age or older must have a BMI of greater than or equal to 35 kg/m2.

  • The client, regardless of age, has at least one major, or two lesser comorbid conditions as follows:

     

    

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.