Does medicare cover bariatric surgery? Do they cover gastric sleeve surgery? Is there a co-pay?
Bariatric surgery is excluded under many of their benefit plans and is governed by both state and federal mandates. Refer to your benefit plan document to determine availability and the terms and conditions of your coverage. Unless it is excluded from your benefit plan, bariatric surgery is covered when medically necessary. Cigna covers bariatric medicine for the treatment of morbid obesity.
Surgery Criteria
Individuals must be over the age of 18 and reach their expected growth and have evidence of one of the following:
- a Body Mass Index (BMI) of over 40,
- a BMI over 35 with at least one co-morbidity including high blood pressure, high cholesterol, coronary artery disease, Type II Diabetes, hyperlipidemia, obstructive sleep apnea, and pulmonary hypertension (others may apply).
- Documentation proving the patients has tried to lose weight in the last 12 months to no avail
- An evaluation from a bariatric surgeon in the last six months who recommends surgery, a medical assessment from primary care physician referring the patient to the surgeon, a nutritional assessment from a registered dietician.
Bariatric Surgery Procedures Covered
Cigna Health Insurance covers Roux-en-Y gastric bypass, biliopancreatic diversion with duodenal switch for individuals with a BMI greater than 50, adjustable silicone gastric banding, gastric sleeve (sleeve gastrectomy) as either a staged or stand-alone procedure, and vertical banded gastroplasty.
NOTE: Cigna does cover all lap band adjustments and fills.
Procedures such as Fobi-pouch, intragastric balloon, gastric bypass, duodenojejunal bypass liner, transoral gastroplasty, single-anastomosis DS, vagus nerve blocking, vagus nerve stimulation, mini-gastric bypass are some of the procedures not covered with Cigna Insurance. Make sure that your surgeon ensures that the process you choose is covered by your insurance plan before proceeding.
Revisional/Reparative Bariatric Surgery Coverage
Cigna does cover the replacement of an adjustable silicone gastric band or band removal as medically necessary if there is evidence of malfunction, a faulty component that cannot be repaired or evidence of slippage. This also is covered when the individual develops a significant complication from a procedure. Revisional surgery is covered if a patient doesn’t lose enough weight if the coverage is available in the patient’s plan, the requested method is a regularly covered procedure, and there is evidence of full compliance with the diet and post-op guidelines. Inadequate weight loss is defined by less than 50% of excess weight loss or failure to achieve body weight within 30% of ideal body weight within two years following surgery.
Things to Note Regarding Cigna and Bariatric Surgery Coverage
Cigna does not require a COE designation at this time meaning you can have your surgery wherever your covered surgeon performs procedures. For more specific questions regarding bariatric surgery coverage and CIGNA, call 1-800-CIGNA24 (1-800-244-6224).
