North Carolina's Medicaid Rules for Gastric Bypass

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North Carolina cares for its clinically obese residents.
North Carolina cares for its clinically obese residents. (Image: north carolina outline image by Kim Jones from Fotolia.com)

The North Carolina Department of Health and Human Services (NCDHHS) oversees the state's Medicaid program and what medical services it pays for. As of a July 2008 revision, the NCDHHS clinical coverage policy outlines what medical record reviewers look for to approve applications for Medicaid-covered gastric bypass surgery. Among the criteria for approval are sever obesity and previous failed attempts to lose weight.

Age Requirement

Qualifying Medicaid recipients must be at least 18 years old. However, those under age 18 may be considered for the surgery on a case-by-case basis.

Qualifying Body Mass Index

Successful Medicaid applicants for gastric bypass coverage must have medical record documentation showing two years of consistent body mass index scores of 40 or higher.

Body Mass Index Scores under 40 and other Qualifying Factors

Medicaid applicants with body mass index scores betweeen 35 and 40 for two years may have gastric bypass surgery paid for by the state if there is medical record documentation of any of the following conditions being complicated or caused by clinically severe obesity: diabetes, heart disease, hypertension, disabling physical trauma, respiratory insufficiency or significant circulatory insufficiency.

Alternative Weight Loss Methods - Proof of Necessity

Qualifying applicants must also present medical record documentation of failed attempts to lose weight without surgery, including either a minimum of six months enrollment in physician-supervised nutrition and exercise programs or three months participation in a multidisciplinary surgical preparatory regimen. Failed weight loss efforts may indicate an endocrine disorder.

Psychological Evaluation

Medicaid applicants must present a psychological assessment proving mental suitability for gastric bypass surgery and the ability to comply with post-surgical dietary changes and medical appointments.

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