Does Cigna Cover Weight Loss Surgery?
Contents
- What is Weight Loss Surgery?
- Why Consider Weight Loss Surgery?
- Understanding Cigna Insurance
- Does Cigna Cover Weight Loss Surgery?
- Cigna Weight Loss Surgery Coverage Requirements
- What Procedures Does Cigna Cover?
- What Procedures Does Cigna Not Cover?
- Cigna’s Pre-Approval Process
- In-Network vs Out-of-Network Providers
- Tips for Maximizing Cigna Coverage
- Appeals and Denials
- Final Thoughts
- Sources
Obesity is a major health issue, and weight loss surgery is an option for people who have not reached a healthy weight with other treatments. The cost can be a real barrier.
This guide explains how Cigna covers weight loss surgery, including its medical requirements and limits.
What is Weight Loss Surgery?
Weight loss surgery, also known as bariatric surgery, is a surgical procedure designed to help individuals lose weight by modifying the digestive system.
The most common types include gastric bypass and the gastric sleeve. Adjustable gastric banding is now less common in the United States, according to the NIDDK.
Why Consider Weight Loss Surgery?
Obesity can lead to a variety of health problems, such as heart disease, diabetes, and high blood pressure. Weight loss surgery can help individuals lose a significant amount of weight and improve their overall health and quality of life.
Understanding Cigna Insurance
Cigna is a health insurance company that administers employer and individual plans. Each plan has its own benefit document, and that document decides what is covered.
Does Cigna Cover Weight Loss Surgery?
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Often, yes. Cigna covers weight loss surgery on many plans when it is medically necessary and the patient meets specific criteria.
Some plans exclude bariatric surgery entirely, and state mandates can also apply. Check your own plan document first.
Cigna Weight Loss Surgery Coverage Requirements
Under Cigna's bariatric surgery coverage policy, adults (18 and older) generally need a BMI of 35 or higher. A BMI of 30 to 34.9 can also qualify with at least one significant obesity-related condition, such as diabetes, sleep apnea or poorly controlled high blood pressure.
The policy also calls for a multidisciplinary evaluation within the past 12 months. That includes documented failure of medical weight management, clearance from a mental health provider and a nutrition evaluation. Separate criteria apply to teens.
What Procedures Does Cigna Cover?
When the criteria are met, Cigna's policy lists gastric bypass, sleeve gastrectomy, adjustable gastric banding and duodenal switch procedures as medically necessary. It also lists endoscopic sleeve gastroplasty. Your exact costs depend on your plan and location.
What Procedures Does Cigna Not Cover?
Cigna treats some procedures as experimental or unproven, such as intragastric balloons and certain revision techniques. Gastric pacing and vagus nerve stimulation for weight loss are listed as not medically necessary. Your plan may also have its own exclusions.
Cigna’s Pre-Approval Process
Before surgery, your care team usually has to get prior approval from Cigna. The request includes your medical history, BMI, related conditions and the evaluation results described above.
In-Network vs Out-of-Network Providers
Cigna may offer different coverage and costs for weight loss surgeries depending on whether the patient chooses an in-network or out-of-network provider. In-network providers have agreements with Cigna to provide services at a discounted rate, while out-of-network providers do not.
Tips for Maximizing Cigna Coverage
To maximize their Cigna coverage for weight loss surgery, patients should ensure that they are eligible for coverage before undergoing the procedure. They should also choose an in-network provider and consult with their healthcare provider to determine which weight loss surgery option is best for them.
Appeals and Denials
In some cases, Cigna may deny coverage for weight loss surgery. Patients have the right to appeal this decision and should consult with their healthcare provider to determine the best course of action.
Final Thoughts
Weight loss surgery can greatly improve health for people with obesity and related conditions. Cigna covers weight loss surgery on many plans when the medical criteria are met.
Before you schedule anything, read your plan document, confirm the surgeon is in network and get prior approval in writing.
