Guide to United Healthcare for prospective bariatric patients. What are the requirements for United Healthcare coverage?
Many of United Healthcare’s certificates of coverage exclude weight loss surgery coverage. However, there are some plans that do include this medically necessary procedure under the umbrella coverage portion of their insurance. Some states have laws requires that insurance companies do cover weight loss procedures, so depending on where you live, your policy may exclude it, but if your state mandates it, they are required to cover it.
Pre-Approval Requirements for Bariatric Surgery
It’s important to understand that each state’s requirements are different, so consult your specific insurer directly. Some general conditions to receive coverage from United Healthcare requires that you meet the following criteria:
Have a body mass index over 40 OR
Have a body mass index over 35 with severe comorbidity. Some examples of comorbidities include high blood pressure, high cholesterol, obstructive sleep apnea, Type II Diabetes, angina or stroke.
Proof that you have followed diets in the past, but have been unsuccessful at losing weight. This must be proven in the medical documentation for at least six consecutive months or two plans of three months each.
Be 18 years or older
Surgeries Covered by United Healthcare
Some procedures covered for adults include gastric bypass, gastric sleeve, adjustable gastric bands (Lap Band or Realize Band), Duodenal Switch, Biliopancreatic Bypass and Vertical banded gastroplasty.
For teenagers, the following procedures are covered:
- Gastric band
- Gastric bypass
- Gastric sleeve
If you are having a gastric banding procedure and United Healthcare covers this procedure, they will also include any band fills. These fills are necessary for adjustment of the band, which gives you the patient the best chance at weight loss success.
Bariatric Surgeries Not Covered
- ROSE Procedures
- Mini gastric bypass
- Gastric electrical stimulation
- TOGA procedures
- StomaphyX procedures
Other Things to Consider
For patients who have one system and don’t get the results they seek, United Healthcare will cover additional surgeries as long as the same conditions exist that did initially.
United Healthcare also includes any visits or hospital stays that result from complications or issues following your weight loss surgery (if they added it initially). They do not place any specific requirements on who you visit to have your surgery done through choosing an in-network surgeon significantly reduces your out of pocket costs.
If you have any questions regarding your coverage, call United Healthcare directly at 866-633-2446.
