Medicare and Medicaid for Bariatric Surgery

Medicare and Medicaid cover qualified patients for bariatric surgery. This gives millions of Americans access to bariatric surgery options, and the potential for a new, healthier life. However, while these public insurance programs do cover surgery, they will only do so with evidence of medical necessity. Medicare and Medicaid programs may require some or all of the following, or more:

• A Body Mass index of over 35 with one or more obesity related diseases, or a BMI of 40 or more with or without obesity related diseases.
• Proof of medical necessity. i.e. It would be reasonable to believe that the obesity is causing significant health problems.
• Proof of failed diet and exercise programs.
• Proof of completion of a physician-supervised medical weight loss program.
• Surgery must be performed at a Bariatric Surgery Center of Excellence facility.

Pre-authorization:

One of the biggest drawbacks of using Medicare or Medicaid is the fact that they do not pre-authorize coverage unlike most private insurers. This means that a patient will not know if their surgery is partially or fully covered until after the surgery takes place.

Most surgeons will require the patient to sign for financial responsibility in case part or all of the procedure is not covered. This may result in a significant surgical bill being sent to the patient in case of a denial. Therefore, it is all the more important that patients contact their insurance provider to get a comprehensive list of requirements and ensure that all requirements are met before undergoing surgery.

Appealing a Denial:

Not every application for coverage is approved, but patients do have the option to appeal their denial. It is most important to call the relevant insurance program and request written confirmation of the denial which includes reasons for the denial. Then patients should speak to their primary physician and bariatric surgeon to get help with the appeals process. Sometimes, denials are the result of a simple clerical error and other times more information will be needed to approve coverage. Receiving a denial is not reason to panic.