Cigna Requirement for Weight Loss Surgery

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,
  • Heart disease,
  • High cholesterol,
  • Pulmonary hypertension,
  • Obstructive sleep apnea.

• You need to show that other weight loss programs have failed in the past. This involves attending a medically supervised program for weight loss. This will include monthly documentation of your nutritional program, your exercise program and your weight to show that weight loss surgery is medically necessary.
• You need written documentation that your primary care physician is recommending surgery for weight loss.
• You will also need to undergo a psychological evaluation in order to make sure that you are ready to make the requisite lifestyle changes for weight loss following weight loss surgery.

What Weight Loss Procedures Does Cigna Cover?

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

• Gastric bypass procedures,
• Gastric banding procedures, (Lap Band, Realize Band, band fills)
• Vertical banded gastroplasty,
• Duodenal switch,
• Gastric sleeve procedures.

Part of getting a Lap Band or Realize Band entails regular filling of your band to adjust its tightness and your ability to lose weight accordingly. If Cigna covers and pays for your gastric banding procedure, then they will also cover the required band fills while getting used to your band.

Procedures Cigna Does Not Cover

There are some weight loss surgical procedures which Cigna does not cover. These include:

• Gastric bypass when combined with a gastric band,
• Fobi-Pouch
• Biliopancreatic diversion sans duodenal switch,
• Intra-gastric balloons,
• Loop gastric bypass,
• Natural Orifice Surgery (such as Stomaphyx)

Other Considerations

If you go through with one weight loss surgical procedure and do not achieve the desired results, Cigna may be willing to cover a secondary procedure. Cigna’s primary requirement is that the surgery is deemed unsuccessful, which means that you are unable to lose 50% of your excess body weight after the procedure.

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

Cigna does not have many requirements as to where you need to go to have your weight loss surgery, but choosing an in-network provider is generally your best course of action. When you choose an in-network surgical provider you will find lower out-of-pocket costs, meaning that you will pay less in the end when it comes to this type of procedure. Make sure that you consult Cigna directly to find out what types of weight loss surgery are and are not covered, and to determine whether or not you qualify. The sooner you begin to document your weight loss journey, the sooner you can undergo the weight loss surgery that you need.

Resources:

• How to Appeal Insurance Denial for Weight Loss Surgery
• What Bariatric Surgeries Are Covered By Insurance?