If you’re considering bariatric surgery and wondering whether Cigna covers weight loss surgery, it’s important to understand the key eligibility criteria and insurance requirements.
Cigna does cover bariatric surgery under specific conditions, primarily focusing on patients who meet certain Body Mass Index (BMI) thresholds, 40 or higher, or 35 or higher with one or more obesity-related conditions, such as type 2 diabetes, sleep apnea, or heart disease.
To qualify for coverage, you’ll need to demonstrate that you’ve attempted doctor-supervised weight loss programs and that these efforts were unsuccessful.
Cigna requires documentation of your weight, exercise regimen, and nutritional plan during these programs. Furthermore, the process involves evaluations from a primary care physician, bariatric surgeon, and other healthcare providers, including a mental health evaluation and a nutritional assessment.
Cigna Eligibility Criteria for Bariatric Surgery Coverage
Cigna has specific guidelines that focus on your Body Mass Index (BMI), comorbidities, and the documentation of prior weight loss efforts. Here’s a breakdown of what you need to know:
1. BMI Requirements
Cigna typically covers surgery if you have a BMI of 40 or higher or if your BMI is 35 or greater with additional obesity-related health conditions. These conditions include type 2 diabetes, sleep apnea, hypertension (high blood pressure), and heart disease. These health conditions, also called comorbidities, increase the risks of obesity and may help qualify you for bariatric surgery even if your BMI is slightly lower than 40.
2. Health Conditions (Comorbidities)
In addition to meeting the BMI threshold, having certain obesity-related conditions is crucial. Cigna’s coverage guidelines typically include comorbidities such as:
- Obstructive sleep apnea (OSA)
- Type 2 diabetes
- High cholesterol
- Heart disease
- Pulmonary hypertension
If you suffer from any of these conditions along with being overweight or obese, you are more likely to qualify for weight loss surgery coverage. Obesity-related diseases can lead to severe health problems, and treating these conditions through bariatric surgery can significantly improve your overall health.
3. Failed Supervised Weight Loss Attempts
Before Cigna approved bariatric surgery, you must show that you’ve tried other methods of weight loss under medical supervision. This typically means participating in a doctor-supervised weight loss program. This program should include regular monitoring and documentation of:
- Weight loss progress
- Exercise programs you’ve followed
- Nutritional counseling and adherence to diet plans
These records demonstrate your commitment to losing weight through non-surgical means, and Cigna may require documentation for several months—often ranging from 3 to 12 months—before surgery is considered. The more thorough your supervised weight loss efforts, the stronger your case for surgery approval.
4. Medical Evaluations
As part of the eligibility process, Cigna requires medical evaluations to ensure you are physically and mentally prepared for bariatric surgery. This includes assessments by both your primary care physician and a bariatric surgeon to confirm that you are a suitable candidate for surgery. In addition to these evaluations:
- Mental health evaluations are required to assess your readiness for the lifestyle changes bariatric surgery demands.
- Nutritional evaluations by a registered dietitian or healthcare provider ensure you understand the dietary changes necessary for post-surgery success.
5. Smoking Cessation Requirement
For those who smoke, Cigna generally requires that you quit smoking at least eight weeks prior to surgery. Smoking can significantly increase the risks associated with surgery and recovery, so this requirement is critical to ensuring a safe procedure and a successful recovery.
6. Age Requirement
Typically, Cigna covers bariatric surgery for individuals aged 18 and older, provided they meet the other eligibility requirements. The surgery is typically not covered for minors unless special circumstances exist. It is important to confirm this age requirement with your plan details.
7. Documentation of Morbid Obesity
To qualify for surgery, you must also provide documentation of morbid obesity. This could include:
- A diagnosis from your primary care physician
- Photographic evidence showing the severity of obesity, if needed
Having morbid obesity documented in your medical records is crucial, as Cigna uses this information to assess whether you meet the requirements for bariatric surgery.
See Also: Gastric Sleeve in Turkey
Medical Procedures Covered by Cigna
Some of the most commonly covered procedures by Cigna include:
- Gastric Bypass
- Gastric Bands
- Duodenal Switch
- Vertical Banded Gastroplasty (VBG)
- Lap Band Fills
Medical Procedures Not Covered by Cigna
There are certain procedures that are excluded from their coverage. These include:
- Biliopancreatic Diversion (without gastric band)
- Fobi-Pouch Surgery
- Gastric Bypass with Gastric Band
- Intra-Gastric Balloons
- Loop Gastric Bypass
How to Verify Your Coverage for Bariatric Surgery with Cigna
- Read through your Cigna health insurance policy.
- Look for the sections detailing covered services and exclusions.
- Ensure that bariatric surgery or obesity treatments are listed as covered benefits.
- Check for any requirements such as BMI thresholds, comorbidities, and supervised weight loss programs.
- Call the customer service number on the back of your insurance card.
- Ask detailed questions about bariatric surgery coverage (including eligibility criteria and any limitations).
- If your Cigna coverage is through your employer, consult with your HR department.
- Ask for clarification on group health insurance plan details and bariatric surgery coverage.
- Your bariatric surgeon can help verify Cigna’s eligibility requirements. They can assist in submitting pre-authorization requests and ensuring all documentation is in order.
- Some procedures require pre-authorization from Cigna before surgery.
- Your primary care physician or bariatric surgeon will assist with submitting the request and required documents, such as medical records and BMI.
- Review your out-of-pocket expenses like deductibles, co-pays, and co-insurance.
- Be aware of any restrictions or exclusions that may apply to your procedure or provider.
See Also: Fidelis Medicaid
