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 serious comorbidities, 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,
- 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.
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.
9 thoughts on “United Healthcare Requirement for Weight Loss Surgery”
I am 54 years old and on United healthcare plan I am social security disability also and I weigh 230
I have many medical conditions and my weight is one factor that hurts the conditions that I have I would love to have surgery to help me lose weight
I do not have any thyroids now and can’t lose weight as I need to I am over 100 lbs than I should be.i need to get this excess weight off for my health.i want to do the endoscopic sleeve gastroplasty. I want to keep from doing any surgery .
I want to do the endoscopic sleeve gastroplasty.i am over 100 lbs more than I should be.i have no thyroids.i want to get back to a healthy weight and help my body .this procedure is safer for me as a person.i hope you will help me so I enjoy my life with my family.
I have had thyroid removal and have a very bad back and have had neck surgery plus knee replacement and have gained so much weight am I a candidate for endoscopic gastric surgery I am needing another knee surgery I am 5”1smd almost 100pounds overweight and have sleep apnea sleep with a bi-pap machine. Can I get help
Hello Ramona, The endoscopic sleeve (ESG) is suitable for patients with a BMI of under 35. It is not as effective as Sleeve Gastrectomy (VSG) and requires the patient to be disciplined and active.
38yrs old type 2 diabetic insulin 3xs daily, severe high blood pressure, several lumbar spinal surgeries and haven’t been able to work in quite some time. My husband has UMR through work they’ve denied the ozempic and I am hoping they will accept me for weight loss surgery so I can start to regain my life back and not be on insulin the rest of my life.
You can apply and see if you qualify for weight loss surgery at https://obesityreporter.com/apply-bariatric-surgery-health-questionnaire/
I needed a lap band revision with the removal of the band and a gastric sleeve. The lap band had slipped and twisted. United Healthcare denied the surgery as a revision saying it “wasn’t medically necessary.” However, I was able to have the band removed. I still want the gastric sleeve as I am gaining weight. Can I get the ESG instead? I am disciplined enough as I was one of the few successful lap band patients my surgeon had. I want to finally get and stay at my goal weight.
You can apply and see if you qualify at https://obesityreporter.com/apply-bariatric-surgery-health-questionnaire/