Texas Medicaid, managed by the Texas Health and Human Services Commission (HHSC), provides healthcare coverage for qualifying low-income residents. Bariatric surgery is a high-cost intervention aimed at treating morbid obesity and its related health complications. Texas Medicaid covers weight loss surgery, but coverage is strictly limited to cases that meet defined medical necessity guidelines. Approval is not guaranteed and requires an extensive administrative and clinical process.
General Coverage Status and Limitations
Coverage for weight loss surgery is exclusively provided for procedures deemed medically necessary to address morbid obesity and related health issues. The program does not cover bariatric surgery for aesthetic purposes or for weight reduction for psychological satisfaction. Coverage includes the surgery itself, required pre-operative evaluations (such as psychological and nutritional assessments), and necessary post-operative follow-up care.
Coverage limitations are rooted in state policy, requiring adherence to guidelines outlined in the TMHP Provider Procedures Manual. Providers must follow these regulations to ensure the procedure is a covered benefit. Any procedure that is cosmetic, experimental, or not specifically listed as an approved bariatric service is automatically excluded.
Specific Medical Eligibility Requirements
To qualify for bariatric surgery under Texas Medicaid, a patient must meet clinical thresholds based on their Body Mass Index (BMI) and the presence of co-existing medical conditions. A patient must have a BMI of 40 or greater. Alternatively, a patient may qualify with a BMI of 35 or greater if they have at least one severe obesity-related co-morbidity.
These co-morbidities often include conditions like Type 2 Diabetes Mellitus uncontrolled by medication, severe obstructive sleep apnea, or hypertension resistant to multiple drug treatments. Other qualifying conditions may involve cardiovascular disease, hyperlipidemia, or chronic joint disease. Documentation from a primary care practitioner is necessary to confirm the diagnosis and severity of these conditions.
A fundamental requirement is documented evidence of previous failed attempts at supervised, non-surgical weight loss. This means the patient must have participated in a medically supervised diet program for a sustained period, often six consecutive months, immediately prior to the surgery request.
Before surgery, the patient must undergo a comprehensive pre-operative workup. This includes a psychological evaluation to assess readiness and commitment to post-surgical lifestyle changes. The screening process also mandates detailed nutritional counseling and a full medical evaluation, which may include cardiology or pulmonology assessments, to ensure the patient can safely undergo the operation.
Approved Bariatric Procedures
Texas Medicaid primarily covers bariatric procedures with robust evidence of long-term efficacy and safety. The two most commonly covered procedures are the Roux-en-Y Gastric Bypass (RYGB) and the Sleeve Gastrectomy (SG).
The Roux-en-Y Gastric Bypass is a malabsorptive and restrictive procedure that creates a small stomach pouch and reroutes the small intestine. The Sleeve Gastrectomy is a purely restrictive procedure that removes approximately 80% of the stomach. These two methods are considered the standard of care for surgical treatment of morbid obesity.
Procedures generally excluded or restricted by TMHP include the Adjustable Gastric Banding (Lap-Band) and investigational operations like the Biliopancreatic Diversion with Duodenal Switch. Coverage for a specific procedure is determined by the patient’s clinical profile and the surgeon’s recommendation, but it must be an approved type. Any revision or conversion of a previous bariatric surgery is subject to the same medical necessity criteria and prior authorization process.
The Prior Authorization Process
Even after a patient meets all clinical eligibility requirements, the procedure cannot be scheduled until the provider successfully completes the Prior Authorization (PA) process with TMHP. The surgeon’s office is responsible for compiling and submitting a formal PA request to the Texas Medicaid program. This request is a comprehensive packet demonstrating that the patient meets all medical necessity requirements.
The PA submission must include:
- The physician’s letter of medical necessity.
- The results of the psychological and nutritional evaluations.
- Documentation proving the required six months of failed medically supervised weight loss attempts.
- The patient’s current BMI and the list of qualifying co-morbid conditions.
TMHP reviews this documentation against the rules published in the Texas Medicaid Provider Procedures Manual. If the initial request is denied, the patient and provider have the right to appeal the decision by submitting additional information or a formal reconsideration request. No procedure can be performed without the official authorization number from Texas Medicaid.