Will GA medicaid pay for bariatric surgery?

Answer 1

Obesity, Medicaid and Medicare

Medicaid does not cover obesity, and under Medicare, hospital and physician services for obesity are clearly excluded. Medicaid is a government program that provides health insurance to qualified individuals whose income level is below a certain point. Recipients of Medicaid are primarily women and children who are poor and members of minority groups. Given the high prevalence of obesity among those populations, it could be presumed that many Medicaid recipients are likely to have obesity. Medicare provides health insurance coverage to elderly citizens and disabled Americans who qualify by meeting criteria of the Social Security Administration (SSA) and completing a two-year waiting period.

Medicaid

• In 1990, Congress enacted the Omnibus Budget Reconciliation Act (OBRA), which funds state programs to provide pharmaceutical products to Medicaid recipients.

• A State may choose to exclude or restrict drugs or classes of drugs, or their medical uses for certain purposes. A State choosing to include outpatient drugs within its Medicaid program must cover, for their medically accepted indications, all Food and Drug Administration (FDA) approved prescription drugs of manufacturers that have entered into drug rebate agreements, with a few limited exceptions.

• Exceptions include drugs when used for: anorexia, weight loss or weight gain; to promote fertility; for cosmetic purposes or hair growth; for the symptomatic relief of cough and colds; or to promote smoking cessation.

• As a result of OBRA, the Department of Health and Human Services ordered states to cover Viagra for the treatment of erectile dysfunction while continuing to exclude anti-obesity agents.

• Nine states cover anti-obesity pharmaceutical products including Alaska, California, Kentucky, Montana, North Carolina, Oregon, Rhode Island, Washington and Wisconsin.

• One state, Arizona, covers products by specific managed health care plan.

• In 23 states, there is no specific language regarding coverage under Medicaid.

• In 29 states, anti-obesity products are specifically excluded in state Medicaid programs.

Medicare

• The Medicare Coverage Manual defines obesity and the justification for certain treatment coverage by stating that:

  • Obesity itself cannot be considered an illness. The immediate cause is a caloric intake, which is persistently higher than caloric output.

  • Program payment may not be made for treatment of obesity alone since this treatment is not reasonable and necessary for the diagnosis or treatment of an illness or injury.

  • However, although obesity is not in itself an illness, it may be caused by illnesses such as hypothyroidism, Cushing's disease, and hypothalamic lesions. In addition, obesity can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension. Therefore, services in connection with the treatment of obesity are covered when such services are an integral and necessary part of a course of treatment for one of those illnesses.

• Medicare's limited coverage of obesity is difficult to understand when considering that it does cover services such as inpatient and outpatient alcohol detoxification and rehabilitation, inpatient and outpatient drug rehabilitation, and services for sexual impotence. It also covers chemical aversion therapy for the treatment of Alcoholism even though the FDA has not approved the drugs commonly used in chemical aversion therapy for this application.

Supplemented Fasting

On supplemented fasting, the Medicare Coverage Manual states that:

• Supplemented fasting is a type of very low calorie weight reduction regimen used to achieve rapid weight loss. The reduced calorie intake is supplemented by a mixture of protein, carbohydrates, vitamins and minerals.

• Serious questions exist about the safety of prolonged adherence for two months or more to a very low calorie weight reduction regimen as a general treatment for obesity, because of instances of cardiopathology and sudden death, as well as possible loss of body protein. Therefore, supplemented fasting is not covered as a general treatment for obesity.

• In cases where weight loss is necessary before surgery in order to ameliorate the complications posed by obesity when it coexists with pathological conditions such as cardiac and respiratory diseases, diabetes or hypertension (and other more conservative techniques to achieve this end are not regarded as appropriate), supplemented fasting with adequate monitoring of the patient are covered under Medicare on a case-by-case basis, as determined by your medical consultant.

• The risks associated with the achievement of rapid weight loss must be carefully balanced against the risk posed by the condition requiring surgical treatment.

Gastric Bypass Surgery

Surgery for the treatment of obesity is covered on a limited basis. According to the Medicare Coverage Manual:

• gastric bypass surgery, which is a variation of the gastrojejunostomy, is performed for patients with extreme obesity. Gastric bypass surgery for extreme obesity is covered under the program if:

1. it is medically appropriate for the individual to have such surgery.

2. the surgery is to correct an illness, which caused the obesity or was aggravated by the obesity.