Which Weight Loss Procedures Does Medicaid Cover
In most cases, Medicaid covers Lap-Band Surgery, gastric sleeve surgery, and gastric bypass. These are not only readily covered by Medicaid, but also among the most common surgeries recommended. In certain situations, these are accepted as medically vital to the life and wellbeing of the patient.
Gastric bypass reduces the stomach size and bypasses a part of the intestine. Hence, you eat less and the food is also sent straight to the lower part of your intestine. Due to this bypass, absorption of nutrients and calories is reduced. Hence, it reduces food intake and additionally helps result in weight loss. In Lap-Band surgery, the top part of the stomach is covered with silicone bands with balloons. This reduces the space for holding food. Also, the entry to the stomach becomes smaller. The procedure is less invasive compared to others and is done laparoscopically. Additionally, it is preferable as it is easy to reverse and the band can be adjusted. Finally, in gastric sleeve surgery, a sleeve-shaped, smaller stomach is created. As the food does not have much space to sit, it is readily passed to the intestines. Hence, it too reduces intake of food and calorie absorption.
Criteria For Coverage Of Surgery Costs
In order for Medicaid to cover the cost of your surgery and the associated surgeon visits, you must meet the requirements below.
- Over the age of 13 for a female and 15 for a male.
- Body Mass Index must be over 35 with at least one comorbidity.
- Co-morbidities include sleep apnea, high blood pressure, high cholesterol, diabetes.
You Might Not Qualify for Weight Loss Surgery Coverage if:
- Long-term steroid use
- Inflammatory bowel disease, chronic pancreatitis, pregnancy, or non-compliance with medical treatment.
- Psychological treatment that might interfere with post-operative compliance with diet and lifestyle.
Sclerotherapy For Dilated Gastrojejunostomy
The textbook Townsend: Sabiston Textbook of Surgery states that, in regard to investigational bariatric procedures, “endoscopic incisionless surgery has focused on patients after Roux-en-Y gastric bypass who have inadequate weight loss or significant weight regain and who have a dilated gastrojejunostomy. It is thought that these patients lose restriction because of the dilated gastrojejunostomy and thus overeat. Surgeons have tried endoscopic injection of sclerosing agents to create scar and a smaller anastomosis, with variable effects.”
In a 2007 article, Spaulding, Osler and Patlak studied endoscopic sclerotherapy with sodium morrhuate of a dilated gastrojejunostomy in 147 gastric bypass patients. In a retrospective review, 32 patients were identified for whom > or =12 months of postprocedure data were available. Their weight trends before and after treatment were assessed by paired t test. A total of 32 patients who were gaining weight after gastric bypass underwent sclerotherapy of their dilated gastrojejunostomy. The timing of treatment ranged from 10 to 140 months after Roux-en-Y gastric bypass. Before sclerotherapy, patients were gaining weight at a rate of .36 kg/mo. After treatment, they were losing weight at a rate of .39 kg/mo. After treatment, 56.3% of patients began to lose weight, 34.4% had their weight stabilize, and 9.4% continued to gain weight.
Conversion Of Sleeve Gastrectomy To Roux
Langer and colleagues noted that due to excellent weight loss success in the short-time follow-up, sleeve gastrectomy has gained popularity as the sole and definitive bariatric procedure. In the long-term follow-up, WL failure and intractable severe reflux can necessitate further surgical intervention. These investigators carried out a retrospective analysis of laparoscopic conversions from SG to Roux-en-Y gastric bypass to assess the efficacy for reflux relief and WL success 8 out of 73 patients underwent conversion to RYGB for severe reflux or weight regain after a median interval of 33 months following laparoscopic SG . In 1 of the patients, a banded gastric bypass was performed. In both groups, conversion to RYGB was successful, as proton pump inhibitor medication could be discontinued in all patients presenting with severe reflux, and a significant WL could be achieved in the patients with WR within a median follow-up of 33 months. Post-operative complications were observed in only 1 patient as leakage at the gastrojejunostomy was successfully treated by temporary stent placement. The authors concluded that conversion to RYGB was an effective treatment for WR or intractable reflux symptoms following SG. Therefore, SG could be performed, intended as the sole and definitive bariatric intervention, with conversion from SG to RYGB as an exit strategy for these complications.
Prophylactic Mesh Placement For Prevention Of Incisional Hernia After Open Bariatric Surgery
In a systematic review and meta-analysis, Dasari and colleagues examined if mesh prevents post-operative incisional hernia in open and laparoscopic bariatric surgery patients. A total of 7 studies met inclusion criteria. These investigators abstracted data regarding post-operative IH development, surgical site infection, and seroma or wound leakage and performed a meta-analysis. The prophylactic mesh group had significantly decreased odds of developing IH than the standard closure group . No included studies evaluated outcomes after prophylactic mesh during laparoscopic bariatric surgery. The authors concluded that prophylactic mesh during open bariatric surgery appeared to be beneficial in reducing post-operative IH without significant increasing the odds of surgical site infection or seroma or wound leakage. Moreover, they stated that higher quality studies, including those in laparoscopic patients, and cost-utility analysis, are needed to support routine use of this intervention.
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When Does Medicaid Cover Gastric Bypass Surgery
Therefore, it could take Medicaid several months to approve gastric bypass surgery because you must prove that other less expensive methods are unsuitable to address your needs a far more difficult case to make. Medicaid is likely to cover elective joint replacement surgeries when medically necessary.
Rationale For Intensive Multicomponent Behavioral Intervention
The U.S. Preventive Services Task Force recommends that clinicians offer or refer obese adults to intensive, multicomponent behavioral interventions . The USPSTF found adequate evidence that behavior-based weight loss interventions in adults with obesity can lead to clinically significant improvements in weight status and reduced incidence of type 2 diabetes among adults with obesity and elevated plasma glucose levels. The USPSTF found adequate evidence to bound the harms of intensive, multicomponent behavioral interventions in adults with obesity as small to none, based on the absence of reported harms in the evidence and the noninvasive nature of the interventions.
Most of the intensive behavioral weight loss interventions considered by the USPSTF lasted for 1 to 2 years, and the majority had 12 or more sessions in the first year . Most behavioral interventions encouraged self-monitoring of weight and provided tools to support weight loss or weight loss maintenance .
Among technology-based interventions, intervention components included computer- or web-based intervention modules, web-based self-monitoring, mobile phonebased text messages, smartphone applications, social networking platforms, or DVD learning . Only 1 trial delivered its intervention through print-based tailored materials.
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Contraindications To Obesity Surgery
Surgery for severe obesity is a major surgical intervention with a risk of significant early and late morbidity and of perioperative mortality . Contraindications for these surgical procedures include peri-operative risk of cardiac complications, poor myocardial reserve, significant chronic obstructive airways disease or respiratory dysfunction, non-compliance of medical treatment, psychological disorders of a significant degree that a psychologist/psychiatrist would have thought would be exacerbated or interfere with the long-term management of the patient after the operation, significant eating disorders, or severe hiatal hernia/gastroesophageal reflux.
A Multidisciplinary Care Task Group identified contraindications to weight loss surgery, including unstable or severe coronary artery disease, severe pulmonary disease, portal hypertension with gastric or intestinal varices, and/or other conditions thought to seriously compromise anesthesia or wound healing. The Task Group also noted that weight loss surgery is contraindicated in those who are unable to comprehend basic principles of weight loss surgery or follow operative instructions. The Task Group stated that any combination of the following factors revisional surgery, male, greater than 50 years of age, BMI greater than 50 kg/m2, and obstructive sleep apnea, hypertension, and type 2 diabetes indicates high risk.
Experimental And Investigational Bariatric Surgical Procedures
Aetna considers each of the following procedures experimental and investigational because the peer-reviewed medical literature shows them to be either unsafe or inadequately studied:
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Gastrointestinal Liners For The Treatment Of Obesity
Endoscopic duodenal-jejunal bypass is the endoscopic placement of a duodenal-jejunal bypass sleeve which lines the first section of the small intestine causing food to be absorbed further along the intestine. Once implanted, the device is purported to influence gastrointestinal hormones and satiety. It is suggested to promote weight loss in individuals who are potential candidates for bariatric surgery, but are too heavy to safely undergo the procedure.
An UpToDate review on “Bariatric surgical operations for the management of severe obesity: Descriptions” lists “Endoscopic gastrointestinal bypass devices” as investigational. It states that “Endoscopic gastrointestinal bypass devices A barrier device is deployed to prevent luminal contents from being absorbed in the proximal small intestine. The EndoBarrier is 60-cm long and it extends from the proximal duodenum to the mid-jejunum and thus mimics a duodenojejunal bypass. It is a safe procedure but is hallmarked by an up to 20 % rate of early removal due to patient intolerance. The ValenTx is a 120-cm barrier device that extends from the gastroesophageal junction to the jejunum. This too has a high rate of early removal, but excess weight loss at 3 months was reported to be 40 %, and significant improvement was seen in 7 out of 7 diabetic patients within those 3 months. Data are still lacking about the longevity of these endobarriers and their outcomes once the barrier is removed”.
Is Obesity A Disease
When the American Medical Association officially recognized this in 2013, it was an important step forward educating millions of people, including health care providers, that obesity is not a personal choice or a character flaw. Its a stubborn, difficult-to-treat condition with far-reaching health implications.
The Obesity Medicine Association put this succinctly: For most people suffering with obesity, simply eating less and moving more will not result in sustainable long-term weight loss.
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State Insurance Law Analysis
We reviewed state laws and regulations for private insurance in both the individual and small-group markets for statutory provisions that expressly prohibit or regulate medical insurers’ medical underwriting or eligibility exclusion practices where obesity or health status is used as an independent risk factor and statutory provisions mandating coverage of obesity-related treatments. The 2004 CMS policy change allowed obesity to be considered a medical condition, and, thus, considered under the term health status.
We conducted a state-by-state document review of state insurance laws and regulations obtained via Internet search of the following websites: each state’s Department of Insurance, National Association of Health Underwriters, Georgetown University Health Policy Institute, National Association of Insurance Commissioners, and legal searches of state insurance codes from Westlaw and Lexis Nexis®. We searched state legislature websites for relevant enrolled legislation that had not yet been compiled into the official state code.
Key words included obesity, weight loss, bariatric surgery, mandated coverage, nutritional counseling, morbid obesity, gastric bypass, underwriting, risk factors for underwriting, exclusions, and preexisting conditions.
Medicare Covers Some Bariatric Surgery Procedures
Medicare may cover bariatric surgery such as gastric bypass surgery or laparoscopic banding surgery for beneficiaries who meet certain conditions.2
Medicare covers the following types of bariatric surgeries:
- Open and laparoscopic Roux-en-Y gastric bypass
- Laparoscopic adjustable gastric banding
- Open and laparoscopic biliopancreatic diversion with duodenal switch
In order for Medicare to cover your weight loss bariatric surgery, you must meet the following requirements:
- Have a BMI of 35 or higher
- Have at least one co-morbidity related to obesity
- Have previously undergone medical treatment for obesity, including weight loss programs, but were unsuccessful
Bariatric surgeries performed in an inpatient setting are covered by Medicare Part A .
If you are admitted as a hospital inpatient, Medicare Part A will help cover your hospital costs after you meet your Part A deductible .
If your bariatric surgery is performed in an outpatient setting, Medicare Part B will help cover your costs after you meet your Part B deductible .
After you meet your deductible, you are typically responsible for paying 20 percent of the Medicare-approved amount for your weight loss surgery.
Be sure to check with your doctor and your surgeon about how Medicare will cover your weight loss surgery. If you have a Medicare Advantage plan , check with your plan provider for more coverage information.
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Regulation Of Private Insurance Coverage Of Obesity Treatments
In the group market, six states required or explicitly allowed insurers to offer coverage of certain obesity treatments. The statutes did not specify group size. Only Utah expressly allowed bariatric surgery to be excluded from insurance coverage. The rest were silent.
In the individual market, five states required or explicitly allowed insurers to offer coverage of some obesity treatments. Illinois and South Dakota explicitly allowed insurers to limit or exclude obesity treatments. Utah expressly allowed the exclusion of gastric bypass from coverage in the individual market. The remaining state codes and regulations were silent .
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1 Americas Health Rankings. . . Senior Report. Retrieved from www.americashealthrankings.org/explore/senior/measure/obesity_sr/state/ALL.
2 CMS. Coverage Decision Memorandum for Bariatric Surgery for Treatment of Comorbidities Associated with Morbid Obesity. . Retrieved from www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=160.
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Gathering Approval For Bariatric Surgery
Most Insurance companies will require detailed documentation with your efforts to lose weight in the past. To be prepared, please contact your primary care physician to sign a release to obtain the last two years of medical records. These records will be needed to submit to your Insurance Company to prove medical necessity. If your Insurance Company requires a specific supervised diet program and you have not yet started one, please contact the appropriate provider to start your diet program.
What Are The Requirements For Weight Loss Surgery In Michigan
The duration of the weight loss program should have been at least twelve consecutive months. These may include: Medically supervised weight loss programs. The weight loss surgery should have been prescribed by a physician other than the operating surgeon. The weight loss procedures covered by Blue Cross Michigan include:
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Medicare Part B Covers Diabetes Screenings
If your doctor determines that you are at risk for diabetes or diagnoses you with pre-diabetes, youre eligible for up to two diabetes screenings each year.
Risk factors for diabetes and pre-diabetes include:
- High blood pressure
- History of abnormal cholesterol, triglyceride or glucose levels
- History of high blood sugar
Medicare Part B will also cover your diabetes screenings if two or more of the following situations apply to you:
- Age 65 or older
- Family history of diabetes
- History of gestational diabetes or delivery of a baby of more than nine pounds
Medicare covers diabetes screenings in full when they are performed by a health care provider who accepts Medicare assignment.
Conversion To Sleeve Gastrectomy For Hypoglycemia Post
The 2017 American Society of Metabolic and Bariatric Surgery position statement on “Postprandial hyperinsulinemic hypoglycemia after bariatric surgery” stated that “Conversion of RYGB to SG has also been described in a few small series/case reports for complications related to RYGB. Reversal of RYGB with the addition of primary or staged SG specifically for treatment of refractory hyperinsulinemic hypoglycemia has been described in less than 10 patients with resolution of hypoglycemia symptoms in the majority without findings of short-term weight gain. As with RYGB reversal, these are technically challenging procedures with increased risk of complications, including a greater incidence of gastroesophageal reflux related to the addition of the SG. Currently, there is insufficient evidence to recommend this as treatment for hyperinsulinemic hypoglycemia”.
An UpToDate review on “Late complications of bariatric surgical operations” states that “Based on the theory that severe, disabling hypoglycemia after gastric bypass surgery occurs in a subset of patients with loss of gastric restriction, with resultant rapid food passage and absorption, restoration of gastric restriction can result in symptom resolution. Gastric restriction can be restored by surgical placement of a silastic ring or an adjustable gastric band around the pouch. In one series, symptoms resolved in 11 of 12 patients with this approach”.
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