Obesity is a significant health concern in the United States, with 42% of American adults classified as obese. This condition is associated with numerous adverse health effects, including type 2 diabetes, heart disease, and certain cancers. For individuals who have struggled with traditional weight loss methods, bariatric surgery can be a viable option. United Healthcare (UHC) does offer coverage for some bariatric surgeries for eligible individuals. This article aims to provide a detailed overview of UHC's coverage policies regarding weight loss surgery under Medicare, including eligibility requirements, covered procedures, potential out-of-pocket costs, and steps to take if coverage is denied.
Understanding Bariatric Surgery and its Benefits
Bariatric surgery encompasses various surgical procedures designed to help individuals with obesity lose weight. These procedures work by altering the digestive system to limit food intake or reduce nutrient absorption. Gastric sleeve surgery, also known as laparoscopic sleeve gastrectomy, is a frequently preferred choice for patients. Bariatric surgery can lead to significant weight loss and improvements in obesity-related health conditions, such as type 2 diabetes, hypertension, sleep apnea, and cardiovascular disease.
United Healthcare Coverage for Bariatric Surgery
United Healthcare, as one of the largest health insurance providers in the United States, offers various Medicare plans with different coverage policies. While UHC generally covers certain bariatric surgeries, it's crucial to understand the specific requirements and limitations of your individual plan.
Eligibility Requirements
Like most insurers, United Healthcare has detailed eligibility requirements for bariatric surgeries. While these are general United Health Care eligibility requirements, each plan is unique and may have different or additional needs. To qualify for UHC coverage, individuals typically need to meet the following criteria:
- Body Mass Index (BMI): A BMI of 35 or higher and a documented history of cardiomyopathy, cardiovascular disease, type 2 diabetes, obstructive sleep apnea, or coronary artery disease with surgical intervention. In some cases, a BMI of 40 or higher without any health conditions may also qualify. Some states may demand insurance companies to pay for weight loss surgery.
- Comorbidities: Presence of one or more obesity-related health conditions, such as hypertension, diabetes, sleep apnea, cardiopulmonary conditions, or life-threatening weight-induced medical conditions.
- Prior Weight Loss Attempts: Documentation of unsuccessful attempts at weight loss through other methods, such as medically supervised diets (Weight Watchers, Jenny Craig, etc.), exercise programs, or weight loss medications.
Patients also need to undergo a psychological evaluation and a nutritional evaluation before they can qualify for UnitedHealthcare’s gastric sleeve surgery coverage. An objective examination by a mental health professional (psychiatrist or psychologist) experienced in the evaluation and management of bariatric surgery candidates to exclude patients who are unable to personally provide informed consent, who are unable to comply with a reasonable pre- and postoperative regimen, or who have a significant risk of postoperative decompensation is recommended.
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Covered Procedures
United Healthcare covers many bariatric surgeries, but not all. While UHC covers many bariatric surgeries, but not all. Certain procedures considered experimental may not be covered. The specific procedures covered may vary depending on the plan, but generally include:
- Gastric sleeve surgery (Laparoscopic Sleeve Gastrectomy): This procedure involves removing a portion of the stomach to create a smaller, sleeve-shaped stomach.
- Gastric bypass surgery: This procedure involves creating a small pouch from the stomach and connecting it directly to the small intestine, bypassing a portion of the stomach and small intestine.
Procedures that may not be covered include gastric balloon, endoscopic sleeve, and SADI (Single Anastomosis Duodeno-Ileostomy).
Excluded Coverages
There are many excluded coverages for weight loss surgery with United Healthcare. However, there are several plans that will cover the surgery. It's important to review your specific plan details to understand any exclusions or limitations.
Navigating the Approval Process
Just as each person is different, UnitedHealthcare’s gastric sleeve coverage and pre-approval criteria can be very different for each prospective patient. To determine if your UnitedHealthcare insurance plan covers laparoscopic sleeve gastrectomy, please call or text us now at (855) 690-0565 to verify your insurance details.
Verification of Benefits
The first step is to verify your insurance coverage and understand the specific requirements of your UHC plan.
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Pre-Surgical Evaluations
Prior to covering any laparoscopic sleeve gastrectomy surgery, UnitedHealthcare requires a patient to have a Body Mass Index (BMI) of 35 or greater. As part of the approval process, UHC typically requires patients to undergo several evaluations, including:
- Medical Evaluation: A thorough medical examination to assess your overall health and identify any underlying medical conditions.
- Nutritional Evaluation: An assessment by a registered dietitian to evaluate your dietary habits and provide guidance on pre- and post-operative nutrition.
- Psychological Evaluation: An evaluation by a qualified mental health professional to assess your mental and emotional readiness for surgery and identify any potential psychological barriers to success.
Documentation
It's crucial to gather all necessary documentation to support your request for bariatric surgery coverage. This may include:
- Medical records documenting your BMI and obesity-related health conditions.
- Records of previous weight loss attempts, including diet plans, exercise programs, and medication trials.
- Letters of medical necessity from your primary care physician and other specialists.
- Results of required evaluations.
Out-of-Pocket Costs
Even with eligibility and UHC coverage, your bariatric surgery will have some out-of-pocket costs. Like all insurance providers, UHC plans typically involve out-of-pocket expenses, such as deductibles, co-insurance, and co-pays.
- Deductibles: There are typically two deductibles in your health insurance plan: the individual and family deductibles, both of which reset annually. This is the amount you must pay before your insurance coverage kicks in.
- Co-insurance: Even once your deductible has been met, co-insurance may apply. This means you may share the cost of surgery with UHC up to your out-of-pocket max.
- Co-pays: A fixed amount you pay for each covered service, such as doctor's visits or prescriptions.
- Out-of-Network Costs: United Health Care has a network of preferred health professionals. If you choose to receive care from a provider outside of UHC's network, you may have higher out-of-pocket costs.
It's essential to understand your plan's specific cost-sharing arrangements to budget for these expenses.
Dealing with a Denial of Coverage
You’ve completed all the steps and are excited about the lifestyle changes that await - but you’ve received a denial of coverage from United Health Care. If your request for bariatric surgery coverage is denied, don't lose hope. There are steps you can take to appeal the decision.
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- Contact UHC: First, don’t give up hope. Many denials result from a missing document, incorrect medical coding, or some other small matter that can quickly be resolved with a phone call. Contact UHC to understand the reason for the denial and determine if any additional information or documentation is needed.
- Appeal: When that doesn’t work, it’s time to file an appeal. Appeals exist for this reason. If you believe the denial was unjustified, you have the right to file an appeal with UHC. Follow the instructions provided in the denial letter to submit your appeal, including any supporting documentation.
- Seek Assistance: Your bariatric surgery center can often be an excellent resource when you receive a denial. Consider seeking assistance from your bariatric surgeon's office or a patient advocacy group to navigate the appeals process.
Medicare Coverage Considerations
Medicare does cover weight-loss drugs when they're prescribed for other conditions approved by the FDA. For example, Medicare covers Ozempic, the semaglutide injectable drug used to treat type 2 diabetes, but it won't cover the drug when it's only prescribed for weight loss.
Medicare Requirements
To qualify for Medicare coverage of bariatric procedures, you must have a body mass index of 35 or higher and at least one other condition related to obesity, such as diabetes or heart disease.
Weight loss surgery for Medicare recipients is considered higher risk because often times patients are disabled secondary to their weight and related conditions OR are over the age of 65. Researchers found that adults over 65 will notice the same improvements in quality of life from weight loss surgery that patients in their thirties and forties have.
The Importance of a Multidisciplinary Approach
With or without bariatric surgery, successful obesity management requires adoption and lifelong practice of healthy eating and physical exercise (i.e., lifestyle modification) by the obese patient. Without adequate patient motivation and/or skills needed to make such lifestyle modifications, the benefit of bariatric surgical procedures is severely jeopardized and not medically reasonable or necessary.
Preoperative Psychological/Psychiatric Evaluation
Patients who have a history of psychiatric or psychological disorder or are currently under the care of a psychologist/psychiatrist, or are on psychotropic medications, must undergo preoperative psychological evaluation and clearance and the patient’s record must include documentation of the evaluation and assessment.
Postoperative Care
Appropriate postoperative care for the bariatric surgery patient is required for Medicare coverage of bariatric surgical procedures.