Bulletin Number: MMP 23-46
Distribution: Practitioners, Hospitals, Integrated Care Organizations
Issued: June 30, 2023
Subject: Weight Loss Surgical Procedures
Effective: August 1, 2023
Programs Affected: Medicaid, Healthy Michigan Plan
Medicaid Health Plans (MHPs) and Integrated Care Organizations (ICOs) must provide the full
range of covered services described in this policy at a minimum and may choose to provide
services over and above those specified. MHPs and ICOs are allowed to develop prior
authorization requirements and utilization management and review criteria that differ from Fee
For-Service (FFS) Medicaid requirements. For beneficiaries enrolled in an MHP or ICO, the
provider must check with the plan for applicable requirements.
The purpose of this bulletin is to update the Medicaid program coverage parameters for weight
loss surgical procedures effective for dates of service on and after August 1, 2023. Medicaid
covers a broad array of health services for the treatment of obesity. These services include,
but are not limited to, physician office visits, pharmacotherapy, laboratory, behavioral health,
and surgical interventions.
Gastric bypass, metabolic, and bariatric surgeries, collectively referred to as weight loss
surgeries, involve modifications to the digestive system that promote weight loss. Weight loss
surgery is an evidence-based treatment for obesity resulting in significant weight loss and the
improvement, prevention, or resolution of many associated comorbidities including type 2
diabetes, heart disease and hypertension.
Coverage of Weight Loss Surgery
Weight loss surgery is a covered service for the treatment of obesity when medically indicated
and when the procedure performed is within professional standards of medical practice.
Covered surgical procedures may include, but are not limited to, gastric bypass, gastric band,
sleeve gastrectomy, removal, revision, and/or replacement of adjustable gastric restrictive
devices, and subcutaneous port components and repeat procedures. Procedures considered
investigational/experimental are not covered services. Mandatory participation in a
preoperative weight loss regimen prior to weight loss surgery is not required.
MMP 23-46
Page 2 of 3
Criteria
Body Mass Index
Medically indicated weight loss surgery will be covered for the treatment of obesity in
beneficiaries meeting one or more of the following criteria:
• A body mass index (BMI) > 40 kg/m² regardless of the presence or absence of
co-morbidities; or
• BMI >35kg/m² and < 40kg/m² with at least one co-morbid condition. Common
co-morbid conditions include but are not limited to:
o Coronary artery disease;
o Type-2 diabetes;
o Obstructive sleep apnea;
o Hypertension; or
o Impaired glucose tolerance (diabetes).
• BMI = or <35kg/m² when documentation supports medical necessity including those
beneficiaries who may require weight loss surgery to reduce their BMI in preparation for
other medical procedures.
Beneficiaries are encouraged to have a health behavior/psychosocial assessment by a
licensed mental health provider to identify and address the psychological, behavioral,
emotional, cognitive, and interpersonal factors that may impact the beneficiary’s ability to
successfully achieve the necessary post-operative treatment and healthcare requirements.
Coverage of associated medically necessary reconstructive procedures directly attributable to
weight loss surgery, such as panniculectomy procedures, will be considered through the prior
authorization (PA) process. Providers must obtain a separate PA for these services.
Prior Authorization
PA is required for weight loss surgeries. Requests must include a completed, signed, and
dated MSA-6544-B – Practitioner Special Services Prior-Approval – Request/Authorization
form. If submitting the prior authorization request electronically via direct data entry in the
Community Health Automated Medicaid Processing System (CHAMPS), this PA request form
is not required. PA requests must include the medical history, past and current treatment and
results, complications encountered, results of the health behavior/psychosocial assessment
(when indicated) and expected benefits or prognosis for the method requested.
Refer to the General Information for Providers Chapter and the Directory Appendix of the
MDHHS Medicaid Provider Manual for additional language and webpage location of Fee-for-
Service Medicaid Prior Authorization Criteria.
MMP 23-46
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Questions
Any questions regarding this bulletin should be directed to Provider Inquiry, Department
of Health and Human Services, P.O. Box 30731, Lansing, Michigan 48909-8231, or e-
mailed to ProviderSupport@michigan.gov. When you submit an e-mail, be sure to
include your name, affiliation, NPI number, and phone number so you may be
contacted if necessary. Typical Providers may phone toll-free 1-800-292-2550. Atypical
Providers may phone toll-free 1-800-979-4662.
An electronic copy of this document is available at www.michigan.gov/medicaidproviders
>> Policy, Letters & Forms.
Approved
Meghan E. Groen, Director
Behavioral and Physical Health and Aging Services Administration
