The gastric sleeve, or Laparoscopic Sleeve Gastrectomy (LSG), is a surgical procedure that addresses morbid obesity by permanently reducing the size of the stomach. This intervention involves removing approximately 80% of the stomach, leaving a narrow, tube-shaped section. The primary goal is to restrict food intake and induce hormonal changes that help manage appetite and blood sugar control. This procedure represents a significant step in the long-term management of severe obesity and its related health complications.
Coverage of Gastric Sleeve by NC Medicaid
North Carolina’s Medicaid program, administered by the Division of Health Benefits (DHB), covers the gastric sleeve procedure only when specific medical necessity criteria are satisfied. Coverage is outlined in the state’s clinical policy for surgery addressing clinically severe or morbid obesity, explicitly including Laparoscopic Sleeve Gastrectomy. The procedure is considered a medically appropriate treatment for individuals whose obesity poses a substantial threat to their health, not a cosmetic surgery or simple weight-loss solution. Prior authorization from NC Medicaid is required before the surgery can be scheduled or performed. Without this official approval, the claim will be denied.
Specific Patient Eligibility Requirements
To be considered eligible for a gastric sleeve through NC Medicaid, an individual must meet stringent medical and behavioral qualifications demonstrating the severity of their condition and their readiness for a permanent lifestyle change. The most straightforward requirement relates to Body Mass Index (BMI), which must be 40 kg/m² or greater, a classification known as morbid obesity. Coverage is also extended to those with a BMI of 35 kg/m² or greater, provided they also have at least one significant co-morbid condition that is directly related to their obesity. NC Medicaid will not approve the procedure for any beneficiary with a BMI below 35 kg/m².
These co-morbidities often include conditions like Type 2 Diabetes Mellitus, severe obstructive sleep apnea, or cardiovascular disease. Documentation from a physician must confirm the presence and severity of these health issues to justify the medical need for the surgery.
A mandatory behavioral requirement involves a documented history of unsuccessful attempts at non-surgical weight management. The patient must show they have been under a medical provider’s supervision for weight-related treatment for at least the past twelve calendar months before the surgery request. Within that twelve-month period, a structured, medically supervised weight loss program of at least three consecutive months is required.
The applicant must also undergo a comprehensive psychological evaluation performed by a licensed professional within six calendar months of the request. This evaluation serves to document the absence of significant mental health issues that could hinder compliance with the demanding post-operative regimen. The assessment must confirm the patient understands the procedure, its risks, and the commitment to lifelong dietary and physical activity changes required for a successful outcome.
A separate, face-to-face evaluation by a registered dietitian or nutritionist is required within the six months prior to the request. This professional assesses the patient’s diet history and confirms their suitability to adhere to the strict post-operative dietary guidelines. The surgeon may also impose additional pre-surgical requirements, such as weight loss or smoking cessation, which must be met and documented before the application is submitted.
Navigating the Pre-Authorization Process
Once the patient has successfully met all the medical, behavioral, and documentation requirements, the administrative phase of pre-authorization begins. The bariatric surgical center or the ordering physician is responsible for compiling the complete prior approval request packet. This packet must contain all the supporting documentation, including the BMI calculations, co-morbidity records, proof of the supervised weight loss program, and the psychological and nutritional evaluation reports.
Submitting the request is most efficiently done online through the NCTracks Provider Portal, though mail or fax submissions are also accepted by the Utilization Review Contractor. The packet must also include documentation that the facility where the surgery will take place is accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). This accreditation ensures the facility meets rigorous standards for patient safety and quality of care.
NC Medicaid makes an effort to render a decision on prior approval requests within fifteen business days of receiving a complete submission. However, this timeline can be delayed if the contractor determines the packet is incomplete and requests additional information from the provider. Approval is not a guarantee of payment, as the beneficiary must remain eligible for Medicaid coverage on the actual date the service is rendered.
If the prior authorization request is denied, the Medicaid beneficiary has the right to appeal the decision. The provider receives notice of the adverse decision and can assist the patient in navigating the due process rights, which allow for a review of the denial.