How to Get Medi-Cal to Pay for a Gastric Bypass

Recent statistics reveal that ​42.4 percent​ of Americans can be classified as obese. Although that prevalence is lower in California, ​30.3​ out of every ​100​ Californians also fit the criteria for obesity, according to figures compiled by the Centers for Disease Control (CDC).

This is not a matter of appearance. Significant extra weight is implicated in diabetes, high blood pressure, heart disease and a host of musculoskeletal problems. Such cases suffer a degraded quality of life. Some hope, however, lies with the improved surgical techniques that can arrest and reverse obesity. One such method is gastric bypass surgery. It is often successful, but it’s always expensive.

What Is Gastric Bypass Surgery?

Several procedures fall under the umbrella term of "bariatric surgery." Among them are sleeve gastrectomy and gastric banding. The former removes a large portion of the stomach, leaving only a small section the size of a banana behind. Gastric banding, on the other hand, is akin to placing a belt around the stomach and constricting it so less food is taken in.

Apart from these techniques, gastric bypass, as its name implies, is a procedure whereby the surgeon redesigns the stomach and small intestine so, not only is there a smaller capacity for food, but appetite is inhibited and gut hormones are altered.

Best Candidates for Gastric Bypass Surgery

There is no formula for determining who will best benefit from, and be least harmed by, gastric bypass surgery. Still, because of the way it changes digestive metabolism, it is considered an effective treatment for obese diabetics. Both short-term and long-term results are impressive: ​60 to 80 percent​ of excess weight is shed within a year and a half, while an average of ​50 percent​ stays off for good.

The American Society for Metabolic and Bariatric Surgery (ASMBS) recommends that only prospects with the following conditions should seek gastric bypass:

  • Be at least ​100 pounds​ overweight or possess a body-mass index (BMI) greater than or equal to ​40
  • Have a BMI of ​35​ or more in addition to a co-morbidity like Type 2 diabetes or hypertension
  • Show a history of incapacity to lose weight or keep it off

Again, many other individual factors can affect the suitability of this surgery; these, nevertheless, serve as general guidelines.

Does This Surgery Have Any Drawbacks?

Complications after surgery occur at a slightly higher rate than those following a sleeve gastrectomy, for example. Yet many of these are related to ignoring post-surgical instructions such as a prohibition against taking aspirin. Because gastric bypass re-engineers the digestive system, some nutrients will have to be taken in the form of supplementation, for life.

Will Medi-Cal Cover Gastric Bypass?

Gastric bypass surgery is an expensive undertaking, pricier than other weight-loss programs covered by Medi-Cal. Few people have such funds readily available and hence rely on insurance. In fact, most insurance companies will cover bariatric surgery, and Medi-Cal is no exception.

Essentially, Medi-Cal is federal Medicaid administered by the Golden State, providing a broad range of health care services to low-income families and individuals. The agency will pay for what Medicaid pays for, but not without sufficient cause.

The first thing an inquiring patient must do is to acquire a referral from a primary care doctor to a Medi-Cal affiliated bariatric surgeon. If the surgeon determines, by a thorough examination, that the patient conforms to the criteria listed above, the doctor will issue a letter informing Medi-Cal that the surgery is necessary for life and health.