We’re glad you’re visiting our website to learn more about Medicare bariatric surgery guidelines.
If you are covered under Medicare, please read the following Surgery Requirements and print this form and bring to your family Doctor.
A. Covered Procedures that Nusbaum Weight Loss Centers of New Jersey does:
Laparoscopic Adjustable Gastric Band and Gastric Sleeve
B. To qualify for weight loss surgery Medicare requires that the patient complete ALL 4 of the following requirements listed below:
1.Have a Body Mass Index (BMI) of 35 or greater at the time of surgery. Check Your Body Mass Index (BMI).
2.Have at least ONE of the following diagnosed health conditions
- Type II diabetes mellitus (by American Diabetes Association diagnostic criteria).
- Refractory hypertension (defined as blood pressure of 140 mmHg systolic and/or 90 mmHg diastolic despite medical treatment with maximal doses of three antihypertensive medications).
- Refractory hyperlipidemia (acceptable levels of lipids unachievable with diet and maximum doses of lipid-lowering medications).
- Obesity-induced cardiomyopathy.
- Clinically significant obstructive sleep apnea.
- Obesity-related hypoventilation.
- Pseudotumor cerebri (documented idiopathic intracerebral hypertension).
- Severe arthropathy of spine and/or weight-bearing joints (when obesity prohibits appropriate surgical management of joint dysfunction treatable but for the obesity).
- Hepatic steatosis without evidence of active inflammation.
3. Have been previously unsuccessful with medical treatment for obesity (documentation must be provided by family doctor of failed diet attempts).
4. Psychological Evaluation
C. Contraindications to Bariatric Surgery according to Medicare Bariatric Surgery Guidelines
Surgery for severe obesity is a major surgical intervention with a risk of significant early and late morbidity and perioperative mortality. Surgery for severe obesity is not covered in the presence of absolute contraindications, including the following:
- Prohibitive perioperative risk of cardiac complications due to cardiac ischemia or myocardial dysfunction.
- Severe chronic obstructive airway disease or respiratory dysfunction.
- Non-compliance with medical treatment of obesity or treatment of other chronic medical condition.
- Failure to cease tobacco use.
- Psychological/psychiatric conditions:
- Schizophrenia, borderline personality disorder, suicidal ideation, severe or recurrent depression, or bipolar affective disorders with difficult-to-control manifestations (e.g., history of recurrent lapses in control or recurrent failure to comply with management regimen).
- Mental retardation that prevents personally provided informed consent or the ability to understand and comply with a reasonable pre and postoperative regimen.
- Any other psychological/psychiatric disorder that, in the opinion of a psychologist/psychiatrist, imparts a significant risk of psychological/psychiatric decompensation or interference with the long-term postoperative management.
Note: A history of or presence of mild, uncomplicated and adequately treated depression due to obesity is not normally considered a contraindication to obesity surgery.
- History of significant eating disorders, including anorexia nervosa, bulimia and pica (sand, clay, or other abnormal substance).
- Severe hiatal hernia/gastroesophageal reflux (for purely restrictive procedures such as LAGB).
- Autoimmune and rheumatological disorders (including inflammatory bowel diseases and vasculitides) that will be exacerbated by the presence of intra-abdominal foreign bodies (for LAGB procedure).
- Hepatic disease with prior documented inflammation, portal hypertension or ascites.
If you are in New Jersey or surrounding areas and have questions regarding Medicare weight loss guidelines, please call us today at 973.998.9833