Insurance Requirements

It is the patient's responsibility to call their insurance carriers member service department to verify the benefit and requirements for obesity surgery. All insurance carriers provide the benefit to cover obesity surgery, but some employers elect not to provide the benefit.

All insurance carriers require that patients meet the standard requirement, as listed below:

  • Surgical treatment of morbid obesity — a condition in which an individual's Body Mass Index (BMI) is greater than 35 with documented comorbidities or a BMI of 40 or greater without documented co morbidities
  • Eligible patients must be age 18 or over
  CIGNA

CAREFIRST BCBS (excluding fep groups 104 and 105)

  • Attempted a structured weight loss program for (6) consecutive months or (2) structured diet programs for (3) consecutive months within the last (2) years; can include: Weight Watchers, Jenny Craig, of LA Weight Loss Centers (receipts are required as proof of participation)
  • Psychological evaluation
  • Nutritionist
  • Letter from PCP
  • Maryland based small groups do not have the covered benefit for obesity surgery.
    Patients must have a referral if required by plan.
  • National Accounts — need to check each patient's account; may have the clause "if deemed medically necessary"

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AETNA

  • Weight documented once a year for (2) years
  • Psychological evaluation

    6-Month Program
  • Proof of participation in a medically physician supervised nutrition and exercise program within the last (2 years for a consecutive (6) months (Note: A physician's summary letter is not sufficient documentation).
  • Nutrition evaluation

    3-Month Program
  • Multidisciplinary surgical preparatory regimen: member must participate in an organized surgical preparatory regimen of at least three consecutive months (each specialist) duration, proximate to the time of surgery, meeting all of the following criteria; (1) consultation with a dietician or nutritionist, (2) a reduced-calorie diet program supervised by a dietician or nutritionist, (3) an exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional, (4) behavior modification program supervised by a qualified professional, (5) documentation in the medical record of participation, should include medical records of the physician's initial assessment, and an assessment of the member's progress at the completion of the multidisciplinary surgical preparatory regimen

CIGNA

  • Clinical documentation of a physician supervised weight loss program with a duration of six (6) consecutive months within the last 2 years (5 yrs. if lifelong obesity)
  • Letter for your primary care physician that includes your current medications, any known history of alcohol abuse, a recommendation for gastric bypass surgery
  • Psychological evaluation
  • Nutritional evaluation

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Mamsi/Alliance PPO/M.D.I.P.A./Optimum Choice (United Healthcare)

  • Letter of Medical Necessity from PCP, to include documentation of smoking status, the name of smoking cessation program and the progress if currently smoking: and additional office notes documenting the use of medication for weight loss
  • Participation in a structured diet program weight loss program during the last (2) years for (6) consecutive months of (2) programs for (3) consecutive months
  • Psychological evaluation

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Mail Handlers

  • Participation in a physician supervised weight loss program during the last (6) months for a consecutive (3) months
  • PCP letter
  • Cardiologist
  • Pulmonologist
  • Gastroenterologist
  • Psychological evaluation
  • Nutritional evaluation
  • TSH
  • Post surgical regimen

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DC Chartered Health/Healthright Medicaid

  • The plan will evaluate on a case by case basis, as there are limited benefits for obesity surgery
  • 6 month physician supervised weight management program
  • TSH
  • All specialist testing

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DC Medicaid

  • (1) year physician supervised weight management program
  • Photos of body only
  • All specialists testing

Amerigroup, MD (Case-by-Case basis)

  • Letter documenting obesity for five years
  • Psychological Evaluation
  • EKG
  • EGD
  • Drug and alcohol screening
  • Letter from PCP
  • Supervised diet monitoring for 6 consecutive months w/i (1) yr.
    (Nutritionist, Weight Watchers, or Jenny Craig is acceptable)
  • Additional information maybe requested upon review

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MD Medicaid

  • All testing is reviewed, then it is determined whether weight management will be required

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