Gastric sleeve surgery is a type of weight loss surgery that removes about 80% of the stomach, leaving a small, banana-shaped pouch.
This surgery helps people lose weight by reducing their appetite and limiting their food intake.
Gastric sleeve surgery can also improve or resolve many obesity-related health problems, such as diabetes, high blood pressure, sleep apnea, and more.
But does Medicaid cover gastric sleeve surgery? And if so, how can you qualify for it?
In this article, we will answer these questions and more.
Does Medicaid Cover Gastric Sleeve
Medicaid is a health insurance program for low-income people and groups, such as disabled, pregnant, elderly, and children.
Medicaid may pay for gastric sleeve surgery, a weight loss surgery that cuts most of the stomach, if you need it and meet some criteria.
But not all states cover this surgery.
To get covered, you must have a BMI of 35 or more with a health problem from obesity, or a BMI of 40 or more.
You must also pass a mental test, do a weight loss program for six months, and pick a certified surgeon and facility.
You must also ask your state’s Medicaid to approve your surgery and send them your medical papers.
If they say yes, Medicaid will pay for your surgery and visits. If they say no, you can fight their decision.
Medicaid and Weight Loss Surgery
Medicaid is a joint federal and state program that provides health coverage for low-income individuals and families, as well as people with disabilities, pregnant women, children, and seniors.
It covers essential health benefits, including weight loss surgery, if it is medically necessary and meets certain criteria.
However, Medicaid coverage for weight loss surgery varies by state, meaning some states cover it and others do not.
Criteria for Gastric Sleeve Surgery Coverage
If your state’s Medicaid covers weight loss surgery, you will need to meet several requirements to qualify for gastric sleeve surgery. These requirements may differ slightly by state, but generally, they include:
- Being over the age of 13 for females or 15 for males
- Having a body mass index (BMI) of 35 or more with at least one obesity-related health condition, such as diabetes, high blood pressure, sleep apnea, etc. Or having a BMI of 40 or more with or without any health conditions
- Having a letter from your primary care physician stating that gastric sleeve surgery is medically necessary for you
- Passing a psychological evaluation to show that you are mentally ready for the surgery and the lifestyle changes that follow
- Showing proof that you have tried and failed to lose weight with other methods, such as diet, exercise, medication, etc. You may need to complete a medically supervised weight loss program for at least six months before the surgery
- Understanding the risks and benefits of the surgery and agreeing to follow the post-operative guidelines, such as dietary changes, vitamin supplementation, follow-up visits, etc.
- Choosing a surgeon and a facility that are certified by the American Society for Metabolic and Bariatric Surgery (ASMBS) or the American College of Surgeons (ACS) as centers of excellence for weight loss surgery
How to Apply for Gastric Sleeve Surgery Coverage
If you meet the criteria for gastric sleeve surgery coverage, you will need to apply for prior authorization from your state’s Medicaid. This is a process where Medicaid reviews your medical records and documents to determine if you are eligible for the surgery. You will need to submit the following information to Medicaid:
- Your personal information, such as name, address, date of birth, social security number, etc.
- Your Medicaid ID number and plan name
- Your BMI and weight history
- Your obesity-related health conditions and medications
- Your letter of medical necessity from your primary care physician
- Your psychological evaluation report
- Your proof of participation in a medically supervised weight loss program
- Your surgeon’s name and contact information
- Your chosen facility’s name and accreditation status
You can submit your application online, by mail, by fax, or by phone, depending on your state’s Medicaid.
Medicaid will review your application and notify you of their decision within a few weeks.
If you are approved, you can schedule your surgery with your surgeon.
If you are denied, you can appeal the decision by following the instructions on your denial letter.
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What’s the minimum BMI for coverage?
Most states require a BMI of 40 or higher, but some might consider lower with specific health conditions. Talk to your doctor about your individual case.
Does Medicaid only cover gastric sleeve?
Not necessarily. They might also cover other bariatric procedures like bypass or lap band, depending on your medical needs and state policies.
What documentation do I need?
Expect to show proof of attempts at other weight-loss methods like diet and medication. You may also need psychological evaluations and lifestyle assessments.
How can I find out my state’s specific rules?
Contact your state’s Medicaid agency directly. They have detailed information about eligibility requirements, covered procedures, and the application process.
Gastric sleeve surgery is a safe and effective way to lose weight and improve your health. Medicaid may cover gastric sleeve surgery if you meet certain criteria and apply for prior authorization. However, Medicaid coverage for weight loss surgery is not guaranteed and depends on your state’s policy. Therefore, it is important to check your state’s Medicaid policy and consult with your doctor before pursuing gastric sleeve surgery.
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