Bariatric surgery, also known as weight loss or metabolic surgery, can be a life-changing option for individuals struggling with obesity and related health issues. If you have Cigna insurance and are considering bariatric surgery, it's essential to understand their coverage requirements, approved procedures, and the steps involved in obtaining pre-authorization.
Cigna's Coverage for Bariatric Surgery
Cigna, a major health insurance provider, offers a variety of plans, some of which cover bariatric surgery for adults and adolescents who meet specific criteria. However, coverage can vary significantly depending on your specific plan, so verifying your benefits and familiarizing yourself with your policy language is crucial.
General Eligibility Criteria
Cigna outlines general eligibility criteria for bariatric surgery, including:
- A Body Mass Index (BMI) of 40 or higher.
- A BMI of 35 to 39 with specific comorbidities such as diabetes, high blood pressure, sleep apnea, GERD, or fatty liver disease.
- For individuals of Asian descent, the BMI thresholds are adjusted to greater than 37 or greater than 32 with co-existing conditions.
- Psychological clearance from a mental health professional.
- Nutritional assessment.
- Evidence that previous medical weight loss efforts have failed.
- Details about the proposed procedure from your surgeon.
Proof of Failed Doctor-Supervised Weight Loss Programs
Most Cigna policies will cover weight loss surgery, but some plans may exclude bariatric surgery. You will also need to show proof of failed doctor-supervised weight loss programs. The program will need to include monthly documentation of these things:
- Weight
- Exercise program
- Nutritional program
Covered Surgical Procedures
Once the pre-qualifications are met, Cigna considers a range of surgical options medically necessary. Approved procedures may include:
Read also: Weight Loss with Ozempic and Cigna
- Gastric sleeve (sleeve gastrectomy)
- Roux-en-Y gastric bypass
- Duodenal switch
- Single-anastomosis duodenal-ileal bypass with sleeve gastrectomy
- Vertical banded gastroplasty
- Adjustable silicone gastric banding
Your plan may also outline additional types of surgeries that are not covered, including experimental or investigational procedures. Cigna of Florida covers for several bariatric procedures. These include the gastric sleeve (sleeve gastrectomy) and the gastric bypass. These are the two most performed weight loss surgeries. There are some bariatric procedures that are not covered by Cigna in Florida. Coverage may be available for a secondary or revision of a bariatric procedure in some circumstances.
Bariatric Center Designations
Cigna has two bariatric center designations - a 3 Star Quality designation and the Center of Excellence (COE) designation. A bariatric treatment facility must be accredited through the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) in either Comprehensive, or Comprehensive with Adolescent accreditation types. Designated bariatric treatment facilities are identified in Cigna's online directory on Cigna.com and myCigna.com. Choosing a designated center may be required by your plan and can also help minimize out-of-pocket costs. Currently, Cigna does not require the COE.
The Pre-Authorization Process
Cigna requires preauthorization for bariatric surgery. This means your healthcare provider must submit documentation supporting the medical necessity of the procedure in order for the surgery to be approved for insurance coverage.
Required Documentation
Commonly required materials include:
- Clinical records and exam notes
- Imaging and lab reports
- Documentation of unsuccessful weight loss attempts that were overseen by a healthcare provider
- Letters of medical necessity from your provider(s)
- Psychological evaluation
- Nutritional counseling
It is important to review your exact Cigna policy criteria to help avoid delay in your pre-approval, but you are responsible for understanding your benefits and coverage.
Read also: Healthy Eating Guide for Cigna Members
Potential Out-of-Pocket Expenses
Even if your plan covers the proposed procedure, you may still encounter out-of-pocket (OOP) expenses. OOP costs will vary depending on the type of plan you have with Cigna, but some typical ones include:
- Meeting your deductible
- Paying a copay or coinsurance
- Penalties for utilizing out-of-network providers or facilities
- Pre- and post-operative care not included in the policy
For most plans, these amounts will reset at the end of the calendar year. Any amount paid through your insurance for medical services during the previous year will not be counted toward your maximum should you roll into a new year. With that in mind, if you had several claims earlier in the year, you may have met or be closer to meeting your maximum out of pocket cost.
Understanding Your Policy
Calling Cigna to discuss your coverage and benefits using the phone number on the back of your insurance card is the best place to start. Your insurance representative can explain the breakdown of your policy and any amount outstanding in your deductible or various policy maximums.
What if Your Claim is Denied?
It isn’t unusual for a claim to be denied on the first pass. If this happens, it is possible that further documentation needs to be provided or that a step was skipped.
Alternative Options
If using insurance benefits is not an option, that isn’t the end of the line. For those who do not receive insurance approval, there are options such as competitive cash pay rates and third-party financing.
Read also: Weight Loss Drug Coverage: Cigna
Important Considerations After Surgery
Think of bariatric surgery as a tool to help you lose weight. It isn't an instant fix. You will still need to eat a healthy diet and get regular exercise.
Dietary Changes
Your doctor will give you specific instructions about what to eat after the surgery. For about the first month after surgery, your stomach can only handle small amounts of soft foods and liquids while you are healing. It's important to try to sip water all day long to avoid becoming dehydrated. Bit by bit, you will be able to add solid foods back into your diet. You must be careful to chew food well and to stop eating when you feel full.
If you drink a lot of high-calorie liquid such as soda or fruit juice, you may not lose weight. If you continually overeat, the stomach may stretch. If your stomach stretches, you will not benefit from your surgery. Your doctor will probably recommend that you work with a dietitian to plan healthy meals that give you enough protein, vitamins, and minerals while you are losing weight. Even with a healthy diet, you probably will need to take vitamin and mineral supplements from now on.
Potential Complications
You will have some belly pain and may need pain medicine for the first week or so after surgery. The cut that the doctor made (incision) may be tender and sore. Because the surgery makes your stomach smaller, you will get full sooner when you eat. Food also may empty into the small intestine too quickly. This is called dumping syndrome. It can cause diarrhea and make you feel faint, shaky, and nauseated. It also can make it hard for your body to get enough nutrition.
Any surgery has risks, including:
- Narrowing of the connection between the stomach and the small intestine.
- Leaking from the stomach into the belly area.
- Gastroesophageal reflux disease (GERD).
- Not getting enough of certain vitamins and minerals.
Depending on the surgery you have, there may be other risks.
Finding a Specialist
If you suffer from any of these conditions and have Cigna insurance, specialists like Dr. Danny Shouhed in Beverly Hills can help guide you through the diagnostic process, treatment planning, and insurance coordination. Dr. Shouhed specializes in advanced, minimally invasive treatments for complex gastrointestinal conditions, including MALS, SMAS, GERD, anti-reflux disorders, and bariatric surgery.