Medicaid typically covers life-sustaining surgeries such as open-heart procedures and operations to remove malignant cancers.
But what about elective procedures that you schedule in advance to address other less threatening conditions? The answer is a resounding “it depends” because many operations fall into a gray area.
Contact the company administering your plan and request precertification. The response will vary based on four questions, which this article addresses for commonly performed surgeries.
- Is it medically necessary?
- Will it affect my vision?
- Is it the least costly alternative?
- Does your state institute special rules?
Medicaid Plastic Surgery
Medicaid is also more likely to cover plastic surgery because it reconstructs facial and body defects, which is often medically necessary. Choosing the correct words and definitions is especially important with this class of operative procedures.
Consumers often misapply terms, and the industry adds to the confusion by conflating the two disciplines. Plastic surgery is distinct from cosmetic procedures reshaping healthy tissue to enhance appearance (see below).
Medicaid could pay for plastic surgery for breast reductions. A claim adjuster might look at two main criteria when determining the medical necessity for mammoplasty procedures that remove excess breast fat, glandular tissue, and skin that causes pain, numbness, or irritation.
- Body Mass Index (BMI) is under 35; otherwise, you are too heavy for approval and need to lose weight first
- The symptoms fit into recognized ICD codes for breast reduction approvals
- 9: 611.1 postural backaches
- 9: 724-5 upper back and neck pain
- 9: 695.89 skin fold irritation (intertrigo or dermatitis)
- 9: 782.0 ulnar nerve numbness
However, Gynecomastia (breast reduction surgery for men) rarely meets the eligibility requirements because man boobs are seldom large enough to qualify.
Medicaid may pay for plastic surgery to correct a deviated septum because a crooked nasal airway represents a facial defect that impairs breathing. A claims administrator might pre-certify a septoplasty for one of these medically necessary reasons.
- Trauma to the septum leads to deformity
- Reconstruction after surgical nasal excisions: tumors, polyps, or ethmoid bone
- Deviated septum that leads to medical disabilities: recurrent pus-filled sinusitis, deformity or nasal spur with significant airway obstruction, recurrent nose bleeds, facial pain originating from the nasal area, impending septal perforation, or obstructive sleep apnea
Medicaid Cosmetic Surgery
Medicaid rarely covers elective cosmetic surgery because it is not medically necessary by definition. Cosmetic procedures reshape healthy tissue to alter or improve appearance.
While cosmetic operations might enhance your sense of self-esteem, it does not correct an underlying health problem, which is the key criterion.
Medicaid will most likely not pay for a tummy tuck except under rare circumstances. This cosmetic surgery typically reshapes otherwise healthy stomach muscles and removes fatty tissue that poses little risk to the patient.
However, a tummy tuck could fall into the medically necessary category if the Abdominoplasty fits one of two narrow criteria.
- Addresses a health condition such as persistent back pain or incontinence
- Performed at the same time as another covered procedure
- Breast reconstruction that requires belly fat
- Hernia repair
Medicaid rarely pays for excess for skin removal surgery after significant weight loss surgery because Panniculectomy typically falls into the cosmetic category. Extra epidermis normally does not pose a health risk.
However, your plan could approve skin removal if you can demonstrate the medical necessity. Be prepared to meet these criteria. Otherwise, scarce financial assistance programs are the only alternative.
- Excess epidermis causes chronic rashes and infections
- You lost more than 100 pounds and maintained a stable weight since
- Bariatric surgery was performed at least twelve months prior
Medicaid rarely pays for Liposuction because targeted fat reduction typically falls into the cosmetic surgery category. Reshaping problem areas of your body that do not respond to diet and exercise is not medically necessary.
However, your plan could approve claims for Liposuction if your surgeon can establish that the procedure treats a covered health condition.
- Lipomas: benign fatty tumors
- Gynecomastia: Abnormal enlargement of male breasts
- Lipodystrophy: Selective absence of adipose tissue
- Axillary hyperhidrosis: Excess armpit sweating
Medicaid Weight Loss Surgery
Medicaid typically covers weight loss surgery and related procedures. However, in addition to the three main precertification rules, you must factor in a fourth consideration – is the recommended method experimental.
- Least costly: diet and exercise programs did not shed the excess pounds, and the type of bariatric surgery is not more expensive than alternate treatments
- Medically necessary: Body Mass Index (BMI) of 35 or greater combined with comorbidity: diabetes, high blood pressure, sleep apnea, high cholesterol
- Regional rules: twenty-three states have insurance mandates for weight loss procedures that might apply to public plans
- Not experimental: the Centers for Medicare & Medicaid Services deems specific procedure as unproven and will not honor claims
For example, Medicaid is more likely to pay for Lap-Band surgery (Laparoscopic Adjustable Gastric Banding) because this weight loss procedure typically costs less than other treatment alternatives.
Lap-Band surgery’s average cost is about $15,000, which is on the lower end of the price continuum. Since the Centers for Medicare & Medicaid Services deems the procedure non-experimental, it is easier to make a strong case for precertification.
On the opposite end of the spectrum, Medicaid is less likely to pay for Gastric Bypass because this weight loss surgery is typically more expensive than other methods.
The average cost of Gastric Bypass is about $24,000, which is much more than other procedures. In this case, a claims adjuster might pre-certify for only the most severely obese patients with a BMI above 40.
Medicaid Joint Replacement
Medicaid is likely to cover elective joint replacement surgeries when medically necessary. Bone-on-bone connections brought on by osteoarthritis (degradation of the cartilage) can cause excruciating pain and rob your ability or use your arms and legs during everyday tasks.
The plan administrator could honor claims when your case meets all three of these conditions.
- Lower cost and less invasive treatments failed to remedy the problem with your joint: Orthotics, Medications (anti-inflammatory and pain management), or physical therapy
- Activities of daily living are impossible given the ongoing joint issue: meal preparation, dressing, driving, or walking
- Medical evidence should verify the diagnosis of advanced osteoarthritis in the joint: severity of discomfort measured against a pain scale, and diagnostic images (bone scans, MRI, CT scan, etc.) showing the severity of the disease
Medicaid is more apt to pay for shoulder replacement surgery when you can show that the ball and socket joint between the scapula and the humerus has deteriorated to the point where you meet all three criteria noted above.
- Prior treatment: a medical doctor prescribed medications and physical therapy, but the shoulder remains dysfunctional
- Activities: you cannot lift and rotate your arm to prepare meals, dress, or drive a car without significant discomfort
- Diagnostic images: show significant arthritis in the ball and socket area that impinges your ability to move your arm freely
Medicaid is more likely to pay for hip replacement surgery when the ball and socket connecting the pelvis and femur degrade enough to meet the three main eligibility rules.
- Prior treatment: a physician prescribed anti-inflammatory drugs and physical therapy to strengthen the hip, but the joint remains unstable and cannot bear weight or pain shoots down one leg
- Activities: you have difficulty bearing weight and cannot walk, climb up and downs stairs, or get into or out of chairs and couches
- Diagnostic images: show severe osteoarthritis in the ball and socket area that hampers the movement of your femur
Medicaid is more likely to pay for knee replacement surgery (arthroplasty) when damage to the conjunction of patella, femur, and tibia causes pain, stiffness, or reduced range of motion.
In addition to medical images and the impact on your daily living activities, a claims adjuster might look more closely at less costly alternatives because of the many options and the procedure’s popularity.
- Non-invasive remedies fail to address the problem
- Modifications in activity including orthotics, braces, rest, and weight loss
- Physical therapy with ice and heat treatments and strengthening exercises
- Medications including oral pain killers and steroid injections
- Other operations for osteoarthritis prove inadequate
- Arthroscopic debridement
- Chondroplasty for cartilage repair
- Osteotomy with axis-correction
The ultimate authority for determining whether Medicaid covers a specific surgical procedure is the company administering your plan. A claim adjuster will issue precertification provided the operation is medically necessary, the least costly alternative, and supported by state rules.
Even a simple surgery for an ingrown toenail, bunion, or hernia is not black or white. Your doctor must establish why the procedure is needed, and the administrator must approve in advance.