United Healthcare Requirement for Weight Loss Surgery

United Healthcare Requirement for Weight Loss Surgery

Many of United Healthcare’s certificates of coverage and summary plan descriptions clearly exclude weight loss surgery coverage, though there are some plans that do include this type of surgery under their umbrella of coverage. Some states have laws requiring that insurance companies cover weight loss procedures, so in some cases even when your policy seems to exclude the coverage, you may still be able to undergo the surgery with insurance coverage if your particular state mandates it.

Pre-Approval Requirements for Weight Loss Surgery with United Healthcare

In order to receive coverage from United Healthcare, you absolutely must meet the following criteria:

  • You need to have a Body Mass Index (BMI) greater than 40, which is Class III obesity.
  • You need to have a Body Mass Index (BMI) greater than 35 with a serious comorbidity, such as hypertension, angina, stroke, type 2 diabetes or severe sleep apnea, which is Class II obesity.

In Maryland, the requirements are a little different.

  • You need to have a BMI exceeding 40 without any comorbidities,
  • You need to have a BMI exceeding 35 coupled with one of the following comorbidities:
    • Sleep apnea,
    • Hypertension,
    • Diabetes,
    • Cardiopulmonary conditions,
    • Other weight-induced life threatening medical conditions.
  • You must also show proof that you have followed diets in the past but have been unsuccessful at losing weight. This may include a single structured diet plan for a period of at least 6 consecutive months, or two different structured diet plans for a period of three consecutive months each.
  • You need to be 18 years old, or older.

Surgeries Covered by United Healthcare

  • Gastric bypass,
  • Adjustable gastric bands, (Lap Band, Realize Band)
  • Gastric sleeve procedures,
  • Vertical banded gastroplasty procedures,
  • Duodenal switch procedures,
  • Biliopancreatic bypass procedures,

In adolescents, the following procedures are covered:

  • Gastric bypass procedures,
  • Gastric band procedures,
  • Gastric sleeve procedures.

If you are undergoing a gastric banding procedure, such as the installation of a Lap Band or a Realize Band, and United Healthcare covers this procedure, then they will also cover lap gastric band fills. These fills are necessary for the ongoing adjustment of your band, providing you with the best chance of losing weight and balancing your lifestyle for good health.

Procedures United Healthcare Doesn’t Cover

  • ‘Mini’ Gastric bypass procedures,
  • ROSE procedures
  • TOGA procedures
  • StomaphyX procedures
  • Gastric electrical stimulation.

Additional Considerations

For patients who undergo one procedure and do not get the results that they seek, United Healthcare can cover additional weight loss surgeries as long as the same conditions still exist. For example, if you undergo a Lap Band procedure but still have a BMI exceeding 40, then United Healthcare will likely cover a different type of weight loss surgery, such as the Gastric Bypass.

United Healthcare will also cover any hospital stays or visits that result from complications or other issues following your weight loss surgery, assuming United Healthcare covered your initial weight loss surgery. United Healthcare does not place many requirements on who you visit to have your weight loss surgery procedure done, though by choosing an in-network surgeon you will be able to cut down your out of pocket costs.

If you have questions about United Healthcare and their coverage of weight loss procedures, or about whether or not you qualify for this type of procedure, contact United Healthcare directly. Learning about the requirements of your individual policy is the best way to determine what will and will not be covered in this procedure.