Bariatric surgery, commonly referred to as weight loss surgery, involves making changes to the digestive system to help patients lose weight and improve health. In Illinois, Medicaid, administered by the Department of Healthcare and Family Services (HFS), recognizes the medical necessity of these procedures for certain individuals. For eligible recipients, the financial barrier to this surgery is significantly reduced, provided they navigate a strict process of medical evaluation and documentation.
Illinois Medicaid Coverage Status for Bariatric Surgery
Illinois Medicaid covers bariatric surgery only when the procedure is medically necessary and specific administrative rules are followed. This coverage determination is codified within the Illinois Administrative Code, addressing surgical procedures for morbid obesity. Coverage applies to recipients enrolled in traditional Medicaid fee-for-service plans and those managed by Managed Care Organizations (MCOs) operating within the state.
All MCOs must adhere to the medical necessity criteria established by HFS. The state mandates prior approval for surgery to ensure compliance with all clinical and administrative requirements before the procedure is performed. This oversight ensures the surgery is reserved for patients who meet all predefined criteria, rather than being the first line of treatment.
Patient Eligibility Criteria
To be considered for coverage, an adult patient must meet specific Body Mass Index (BMI) thresholds. Eligibility requires a BMI of 40 or greater, with no other required medical conditions. Alternatively, a patient with a BMI between 35.0 and 39.9 may qualify if they have at least one severe co-morbidity related to their obesity.
These co-morbidities include Type 2 diabetes mellitus, medically refractory hypertension, or severe cardiovascular problems. Respiratory issues such as obstructive sleep apnea or pulmonary hypertension also qualify. Furthermore, the patient must be 18 years of age or older, although rigorous criteria exist for adolescents.
Eligibility requires a documented history of unsuccessful non-surgical weight loss attempts. Patients must demonstrate participation in a continuous, medically supervised weight loss program for six months. This program must have occurred within the year immediately preceding the request for prior authorization. Documentation must show that traditional methods like diet and exercise failed to achieve sustained weight loss.
Required Steps for Prior Authorization
Securing coverage requires a prior authorization (PA) process submitted to HFS or the appropriate MCO, which must document the patient’s eligibility. The medical provider must submit a formal request on the required form, such as the HFS 1409 Prior Authorization Request Form, along with clinical records. This submission must include a detailed medical history and physical examination, documenting the patient’s height, weight, and BMI.
A current psychological evaluation is mandatory, performed by a licensed independent behavioral specialist. This assessment ensures the patient is an appropriate candidate, confirming their emotional stability and ability to adhere to the demanding post-surgical lifestyle changes. The evaluation also rules out untreated psychological disorders as the primary cause of obesity.
Documentation of nutritional counseling is also required, detailing the patient’s dietary history and commitment to long-term dietary modification. The provider must submit evidence of the required six consecutive months of the medically supervised weight loss program, which often involves working with a registered dietitian. All supporting documents must be submitted together to establish medical necessity and initiate the approval process.
Types of Surgical Procedures Covered
Illinois Medicaid covers several common bariatric procedures, provided they meet medical necessity requirements. The Roux-en-Y Gastric Bypass (RYGB) is covered, involving the creation of a small stomach pouch and rerouting the small intestine. The Laparoscopic Sleeve Gastrectomy (SG) is also covered, which permanently removes a large portion of the stomach.
Adjustable Gastric Banding is covered by some MCOs, but it is not always the preferred procedure, and coverage can vary. Procedures like gastric balloon insertion and gastric stapling are explicitly excluded from coverage by Illinois Medicaid. Revisional bariatric surgery may also be covered, but only if the initial surgery was covered and the revision is medically necessary due to complications or inadequate weight loss after a minimum of two years.