
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.