Medicaid & Gastric Band Surgery

Since February of 2006, gastric band surgery has been covered as a treatment for morbid obesity by Medicaid. Laparoscopic adjustable gastric banding (LAGB) is the type of gastric banding that Medicaid will cover if specific criteria are met and if it is performed by those that are Medicaid-approved.



In general, adjustable gastric banding (AGB) is covered by Medicaid when it is medically necessary, when the surgery does not exceed patient need, and when there is “no equally effective,” “more conservative” or less expensive treatment available, reports the North Carolina Department of Health and Human Services (NCDHH).

Age and BMI Criteria

• Calipers are often used to measure body fat percentages

  NCDHH states that as of July, 2008: gastric band surgery is covered by Medicaid as a treatment for severe obesity when the patient is at least 18 years old, has a body mass index (BMI) of 40 or over, or has a body mass index of 35 or over with other qualifying criteria.

  Patients under 18 are considered on a case-by-case basis.

  When BMI is 35 to 40, gastric band surgery is covered if there is a record of disease such as diabetes, heart disease or high blood pressure; physical trauma due to obesity documented by x-ray or other tests; breathing problems or sleep apnea; or circulatory problems.

Historical Criteria

• Patients must have documented proof of unsuccessful weight loss attempts

  Medicaid will cover adjustable gastric banding if severe obesity has been present for at least two years.

  The patient must have a proven record of unsuccessful weight loss attempts including medical records documenting doctor-monitored nutrition and exercise program attempts for a total time of at least six months, with at least three consecutive months or a three-month regime in preparation for surgery that includes meeting with a nutritionist and following a reduced-calorie diet, following an exercise program and behavior modification therapy.

Other Criteria

• Patients must be psychologically able and ready to make lifestyle changes

  Adjustable gastric banding (AGB) is covered when there is no other cause for obesity that can be addressed such as a hormonal disorder.

  A psychological evaluation is also part of Medicaid criteria for coverage. This evaluation is meant to illustrate the patient’s suitability for surgery and the likelihood that they will succeed at lifelong dietary changes and medical follow-up. This evaluation includes measurements of depression and suicide, eating behaviors, substance abuse, stress management skills, thinking skills, social skills, self-esteem, relevant personality factors, ability to stick to changes and likelihood to use follow-up services and social support.

When Revision of AGB is Covered

• Second surgeries are only covered if they're medically necessary

  Medicaid will cover surgery when complications occur after initial surgery. These complications include excessive weight loss, esophagitis, hemorrhage, excessive vomiting, stomal dilation, slippage of the gastric band, pouch dilation and problems with absorption such as hypoglycemia and malnutrition.

What Isn’t Covered

• The removal of excess skin and fat are not covered by Medicaid

  Open surgery rather than laparoscopic surgery of AGB is not covered by Medicaid according to the U.S. Department of Health and Human Services (HHS). The NCDHH further states that surgery for severe obesity is not covered if the procedure “unnecessarily duplicates” a previous procedure or surgery that is experimental, investigational or part of a clinical trial.

  Excess skin and fat folds is a consequence of substantial weight loss. Surgery to remove such skin and fat is considered cosmetic surgery and is not covered by Medicaid.

Approved Providers

• A doctor's letter is not enough proof that surgery is necessary

  Medicaid covers adjustable gastric banding when it is performed at a facility certified as a Level 1 Bariatric Surgery Center (BCS) by the American College of Surgeons (ACS) or a facility that has been certified as a Bariatric Surgery Center of Excellence (BSCOE) by the American Society for Bariatric Surgery (ASBS), states the HHS.

  Not all surgeons accept Medicaid insurance as payment for gastric band surgery so it is useful to check that your doctor is a Medicaid provider.