Wednesday, June 15, 2022

Does Cigna Health Insurance Cover Weight Loss Surgery

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How Much Does Gastric Sleeve Surgery Cost

Will Insurance Cover My Weight Loss Surgery?

According to one research, it takes an average of three years from the time you contemplate gastric surgery to the time you actually get it. You may spend many hours studying, reading, and speaking with post-operative patients regarding their procedures.

But, how much is gastric sleeve surgery? A Gastric sleeve surgery costs an average of $23,000, while a gastric bypass surgery costs $14,500, and sleeve gastrectomy surgery costs $14,900. So, before you get too excited, find out if your insurance will cover weight reduction surgery or not.

Patients belonging to the middle to upper classes are the majority of people who undergo this surgery. In addition, most people considering weight reduction surgery may not afford to pay the $20,000 gastric sleeve cost to reduce weight.

However, insurance companies are also beginning to pay weight reduction surgery amounts in more significant numbers than ever before. So, if you are determined to get this even after knowing how much is gastric sleeve surgery, talk to your insurance provider.

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Will My Cigna Insurance Policy Cover Weight Loss Surgery

The first thing to consider when evaluating your Cigna plan for obesity treatment and bariatric surgery is what is covered and what, if anything, is excluded in your policy. You can contact Cigna of Alabama directly, typically through a phone number on the reverse side of your insurance card, or speak with the Human Resources department if the plan is offered through your employer. The exclusions section of the policy should indicate if bariatric surgery or obesity treatment is not a covered benefit of your plan. This is not typical, but does occur in some policies. When weight loss surgery is a covered benefit by your policy, there will usually be a detailed section explaining exactly what is and is not covered in terms of bariatric procedures and obesity treatment. Please note, policies are unique and can vary widely between plans and groups. You should not rely on information outside of what is stated in your specific policy. We encourage all interested patients to contact both Cigna Alabama and our office to learn more about coverage for weight loss surgery and to verify your benefits and eligibility. This is part of our intake process with every bariatric patient.

United Healthcare Bariatric Surgery

Most insurance policies by the United Healthcare dont cover bariatric surgery. But there are some rare plans that include it as long as it is deemed medically necessary by your primary care physician.

Also, if you live in a state where insurance companies are required to cover bariatric procedures, your United Healthcare insurance policy may provide partial or full coverage for the same.

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Other Costs To Consider

When you choose to have gastric sleeve surgery you should also choose to change your lifestyle. Do not expect to keep the same habits that you had before surgery and successfully lose weight. The costs below will probably increase after surgery.

  • Food costs will increase. Even though you will be eating less, you should be eating healthier and eating healthier usually costs more. Maximize every bite of food by choosing the healthiest options that give you the most energy.
  • Will you get a gym membership?
  • Nutritional supplements? Most surgeons recommend protein supplements after surgery. Quality protein supplements can cost $50/month or more.
  • New clothes. As you start shrinking you will want to buy new clothes. Most people are amazed at how fast the weight comes off after surgery. New clothes are essential. Show off your new self!
  • Cosmetic surgery? Some people choose to have cosmetic surgery to remove excess skin after surgery. This is something that can be considered down the road but you may want to start saving early if you feel this is something that you will want to have done.

Medicare Requirements For Bariatric Surgery 2020

Tool: Check Your Weight Loss Surgery Insurance

Their criteria are similar to other insurance companies so if you want to know how to get weight loss surgery approved by Medicare, you must meet the following Medicare requirements for bariatric surgery 2021:

  • You must have a BMI of more than 35.
  • You must have at least one obesity-related health problem
  • You must have struggled with obesity for the last 5 years.
  • You must have legitimate medical documents and health records from those last 5 years.

If you meet all these criteria, Medicare will need you to go through a lengthy process to receive their approval. This Medicare bariatric surgery approval process includes:

  • Having a record of at least 1 attempt at a weight loss program under the supervision of a doctor.
  • Showing proof that you failed at least 1 supervised weight loss program
  • Undergoing blood tests for Pituitary, Adrenal, and Thyroid.
  • Undergoing a full psychological evaluation.

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Where Do I Find Coverage Requirements For My Policy

Each insurance provider will require different documents and different tests. They may also require that you visit approved specialists. These can range from an approved psychotherapist to an approved cardiologist.

The best thing to do is to call your insurance company or your HR department if your insurance is supplied through work. We have our own list that you can check as well.

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How Can They Deny Insurance Coverage For A Life

You may have a specific exclusion in your policy for obesity surgery or treatment of obesity, which reflects the prejudice of our society toward obesity. This exclusion normally cannot be challenged or overturned. You may be able to get an exception by going through your employers benefits division.

Coverage may also be denied for lack of medical necessity, meaning its not deemed a serious or life-threatening condition. Instead, alternative treatments, such as dieting, exercise, behavior modification, and some medications, may be considered to exist according to conventional wisdom. To avoid denials for this reason, be sure to include reasonable, thorough documentation to encourage them to approve your request.

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If Your Insurance Is Through Work: Large Group

If you get your insurance through your work and your employer has 51 or more full time employees, it is completely up to your company to decide whether or not to cover weight loss surgery.

To confirm your coverage, you have a three options:

  • Option 1 : Your local surgeon will contact your insurance company to confirm your benefits for free. Their office will be very familiar with your insurance companys requirements and approval process, so its usually a good idea to let them do the leg work for you. .
  • Option 2: Ask your Human Resources Department whether or not weight loss surgery is an included benefit under your plan.
  • Option 3: Contact your insurance company yourself and/or check your Summary Plan Description . for the full list of United States insurance companies, contact information and bariatric surgery coverage policy details.

If you find out that bariatric surgery insurance is NOT included under your plan, you may want to head over to our Weight Loss Surgery Insurance Secrets page to learn how you may be able to get your company to add the coverage.

If you have short term disability insurance through your employer, you may be able to receive portion of your monthly salary while youre having and recovering from surgery. See our Short Term Disability section for more information.

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Cigna Requirement For Weight Loss Surgery

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Cigna Requirement for Weight Loss Surgery

Most of the insurance policies offered by Cigna do cover weight loss surgical procedures, but there are some benefit plans that specifically exclude it. If you are not sure whether or not your particular plan includes surgical procedures for weight loss, make sure that you contact Cigna directly to find out.

All of the following requirements and criteria for weight loss surgery under Cigna health insurance plans also apply to Great West Healthcare, a provider that Cigna recently merged with.

Requirements for Pre-Approval of Weight Loss Surgery with Cigna

Unless you have a policy that specifically excludes weight loss surgery, surgery is going to be covered provided that you meet specific criteria set forth by Cigna. These requirements include all of the following:

  • You need to be at least 18 years old,
  • You need to have reached your expected skeletal growth,
  • You need to have documented evidence of a BMI exceeding 40, or
  • You need to have documented evidence of a BMI exceeding 35 with a significant comorbidity. Qualifying comorbidities include:
  • Type 2 diabetes,
  • Pulmonary hypertension,
  • Obstructive sleep apnea.

What Weight Loss Procedures Does Cigna Cover?

The procedures that Cigna generally covers will include all of the following.

  • Natural Orifice Surgery

Other Considerations

Remember that excess body weight is defined as the weight that you need to lose, not your total body weight.

Resources:

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What To Do If You Get Declined For Bariatric Surgery

Even if your policy covers bariatric surgery coverage, brace yourself for a possibly long claims process. At best, youll need mounds of documentation to show the surgery is medically necessary for you.

Or you may run into big roadblocks. For CIGNA, the main reason for denials is that the insurer doesnt believe the member met the necessary criteria. In other instances, an employer may not include bariatric surgery in its plan.

If your plan doesnt exclude coverage and youre denied, appeal it. You will probably need to provide further documentation of your need for the surgery as medically necessary.

All health insurance plans should have a clear appeals process. Find out what it is and follow directions. You may only have a limited time from the date you were denied or had the procedure to get an appeal underway, possibly only 60 days. Depending on your plans procedure, you might have to start with a phone complaint and then move to a written appeal.

CIGNA said if a customer has coverage, but medical necessity was not met and a denial was issued, a medical necessity appeal is available to the member or provider. The denial letter would provide the contact information and instructions to initiate the appeal.

If youre thinking about appealing:

If youve tried everything and youre still getting denied, there are a few other options:

  • If your HMO plan doesnt cover obesity surgery, change to a PPO plan at open enrollment if the PPO plan covers it.
  • Cigna Gastric Sleeve Requirements

    You may automatically pre-qualify for Cigna to cover your Gastric Sleeve Surgery in California if:

    • You are 100 pounds or more above ideal weight, or
    • You have a Body Mass Index of 40 or greater, or
    • You have a Body mass Index of 35 or greater and suffer from a weight-related problem that may be life-threatening or cause disability, including cardiovascular disease, mechanical arthropathy, lower extremity lymphatic or venous obstruction, hypertension, hyperlipidemia, type 2 diabetes, severe obstructive sleep apnea, coronary artery disease or pulmonary hypertension.
    • You have been overweight for at least five years, and
    • You have been unsuccessful at all weight-loss attempts including diets, exercise and weight loss programs.

    To see if your Cigna Insurance Plan covers the Gastric Sleeve Surgery, please call us at or fill out our FREE Gastric Sleeve Insurance Verification Form and we will verify your Cigna Gastric Sleeve coverage for you!

    Cignas inception as an insurance company began in Philadelphia’s Independence Hall in 1792 and has grown into a national network with over 500,000 quality health care professionals and over 8,000 hospitals and facilities, offering services in California through Cigna HealthCare of California, Inc. Cigna also offers discount programs for weight management, nutrition products and fitness club memberships.

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    How To Get Bariatric Surgery Added To Your Companys Plan

    SECTION SUMMARY:

    • You should make the business case to your Human Resources Department

    If you work for a company with 51 or more full-time employees and your plan does not currently cover bariatric surgery, you may be able to convince your employer to add it.

    Your first step is to go to Human Resources and present your case. The only way HR is going to get senior management to add bariatric surgery is if HR can present a compelling business reason to do so.

    The trick to presenting a compelling business case to HR is to take all emotions out of the discussion. You should focus strictly on how adding bariatric surgery is a good business decision and will improve your companys bottom line .

    We have good news

    In addition to providing you and others with a benefit that will improve your health and extend your life, adding bariatric surgery to your plan is an extremely good business decision.

    To help your Human Resources department understand why, either:

  • Refer your HR representative to the section below -or-
  • Print and present the following section along with this page on your own.
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    What Are The Types Of Weight

    Does My Health Insurance Cover Weight Loss Surgery

    Depending on whether your weight-loss surgery is to make your stomach smaller or to change the path of your intestine, your doctor will perform one of these procedures:

    Adjustable gastric banding.

    The doctor wraps a band around the upper part of the stomach to make the stomach smaller.

    Gastric sleeve.

    The doctor removes more than half of your stomach, leaving a thin vertical sleeve, or tube.

    Gastric bypass.

    The doctor uses a small part of your stomach to create a smaller stomach. This is connected to the middle part of the small intestine. Food skips the rest of the stomach and part of the small intestine. This surgery is called a Roux-en-Y gastric bypass.

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    Does Cigna Health Insurance Cover Weight Loss Surgery

    Most policies have coverage for weightlosssurgery. Some benefit plans do not include bariatric surgery. If your plan includes weightlosssurgerycoverage, you need to contact Cigna. Great American Life Insurance Company merged with Cigna and is now part of Aetna.

    How Can I Get Weight

    We recommend 6 steps to fast-track insurance approval: 1) a multidisciplinary team 2) 6-month diet 3) comprehensive medical evaluation 4) flexibility and consistency 5) analysis of medical history 6) physical examination and 7) referral to a specialist. We recommend that you consult with your primary care physician before starting any diet or exercise program.

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    Overview Of Gastric Sleeve

    The gastric sleeve procedure also called gastric sleeve resection, vertical sleeve gastrectomy, tube gastrectomy, sleeve gastrectomy, and laparoscopic sleeve gastrectomy is a treatment for obesity considered well worth its cost. It may be performed as the first step before a gastric bypass, or may be performed on its own. During a vertical sleeve gastrectomy, approximately 80% of the clients stomach is removed. The remaining portions of the stomach are then joined, creating a sleeve-like shape. The doctor will use a laparoscope, which is a device with a tiny camera that transmits images to a monitor so that the doctor can enjoy a high degree of precision.

    Since the stomach is now much smaller, the patient feels fuller faster and may lose as much as 75% of their extra pounds. Because the stomach is now secreting fewer hormones, hunger cravings are greatly reduced.

    The gastric sleeve treatment differs from a gastric bypass in that it is a more appropriate surgery for those who are at least 100 pounds or more over their ideal weight. The ideal candidate for gastric bypass should have a BMI of at least 40 as a general rule.

    Healthfirst Requirements For Gastric Sleeve

    Considering Weight Loss Surgery

    Once you have made sure that you are covered, you will need to meet the following HealthFirst requirements for gastric sleeve or any other bariatric surgery:

    • You must be 18 years of age or older.
    • Your BMI must be 40 or higher.
    • Your BMI must be 30-39, and you must also suffer from an obesity-related illness including severe sleep apnea, diabetes, or a cardiovascular disease.
    • You must have no untreated metabolic condition that may be causing your obesity.
    • You must have been overweight for 2-5 years.
    • You must show proof that youve tried losing weight through non-surgical methods.
    • You must be able to pass a psychological evaluation showing that you are capable of making long-term changes to your diet and lifestyle.

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    Is Bariatric Surgery Covered By Insurance

    Alleviating the conditions of morbid obesity may require more than regular exercise and a balanced diet. In such times, bariatric surgery can be your best bet.

    However, for obese patients who qualify for a weight loss surgery, one of the biggest concerns is does insurance cover my bariatric procedure?

    Bariatric surgery is a costly weight loss procedure. The average cost may range between $15,000 and $35,000 across all types of bariatric surgeries in the U.S. The costs are substantially higher even in Canada, Australia, and New Zealand. For any average-income person, paying for the procedure out of their pocket can be considerable. As such, health insurance seems to be a viable option to fund ones bariatric procedures.

    Earlier, most insurance companies did not cover weight loss surgery in their health plans. But with the growing prevalence of bariatric surgery in recent times and even the federal government approving the procedures, many carriers have started to include weight loss surgery in their coverage plans.

    Where Do I Go For Answers About My Insurance Policy Or Carrier

    The customer service number for your insurer will be on your insurance card. You can also visit the insurance companys website, read the most recent insurance handbook from your employer or insurer, or talk to your supervisor or human resources department for questions about your health insurance.

    It is important to understand the terms, conditions and limitations of your coverage. If you have questions about your coverage, contact your employers human resources department or your insurance company directly.

    For more information on weight loss surgery, click here.
    Our accredited program offers a full service, unique weight loss experience. Learn more here.

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