Bariatric surgery, also known as weight loss surgery, is a life-changing procedure for many individuals struggling with obesity. But before undergoing this surgery, insurance companies, such as Cigna, require patients to meet certain criteria. Cigna, one of the largest health insurance providers in the U.S., has specific guidelines and requirements that need to be met to cover bariatric surgery. This article will break down those requirements in a clear, easy-to-understand way.
What Is Bariatric Surgery?
Bariatric surgery refers to a variety of procedures aimed at helping individuals lose significant amounts of weight. These surgeries are usually recommended for individuals who are severely obese and have not been able to achieve or maintain weight loss through diet, exercise, and medication alone. Common types of bariatric surgery include gastric bypass, gastric sleeve, and adjustable gastric banding.
Bariatric surgery works by restricting the amount of food a person can eat, altering how the body absorbs nutrients, or both. These surgeries can lead to substantial weight loss and can also improve or even resolve obesity-related health conditions like type 2 diabetes, hypertension, and sleep apnea.
Why Cigna Covers Bariatric Surgery
Cigna covers bariatric surgery when it is medically necessary. Obesity is a chronic condition that can lead to many serious health issues such as heart disease, stroke, and diabetes. Weight loss surgery is sometimes the most effective long-term solution for individuals who struggle with significant weight issues and related health problems.
However, since it’s a major procedure, Cigna sets specific requirements to ensure that surgery is the appropriate option for the patient. These requirements help ensure that the patient is physically and mentally prepared for the surgery and that they will have the best possible chance of success.
Cigna’s General Requirements for Bariatric Surgery
Cigna has a set of general requirements that patients must meet before they are approved for bariatric surgery. These requirements focus on the patient’s medical history, BMI (Body Mass Index), and attempts at previous weight loss. Below is a breakdown of the key criteria.
1. BMI Requirements
To be eligible for bariatric surgery, Cigna generally requires patients to have:
- A BMI of 40 or greater, which is classified as severe obesity.
- Alternatively, patients with a BMI between 35 and 39.9 may also qualify if they have one or more obesity-related health conditions. These include type 2 diabetes, hypertension, sleep apnea, or heart disease.
2. Medical Necessity
Cigna requires that the surgery is medically necessary. This means the surgery must be essential to improve the patient’s health or prevent serious medical issues. Patients must have health conditions directly related to their obesity, such as:
- Type 2 diabetes
- High blood pressure (hypertension)
- Severe sleep apnea
- Heart disease
- Other conditions that are significantly impacted by weight
3. Documentation of Previous Weight Loss Efforts
Before approving bariatric surgery, Cigna typically requires documentation of previous weight loss attempts. Patients need to show that they have tried to lose weight through:
- Diet and exercise programs
- Medically supervised weight loss programs
- Pharmacological treatment (prescribed weight loss medications)
In most cases, patients are required to participate in a supervised weight management program for at least six months. This program must be documented by a physician or healthcare provider, and it should show that the patient made a sincere effort to lose weight without success.
4. Age Requirements
Cigna usually approves bariatric surgery for adults aged 18 years or older. There may be exceptions for younger individuals, but this is typically reserved for patients with severe obesity and related medical issues that pose a significant threat to their health.
5. Psychological Evaluation
Another critical requirement is undergoing a psychological evaluation. This step is essential to ensure that the patient is mentally prepared for the changes that come with bariatric surgery. Bariatric surgery involves significant lifestyle changes, and patients need to have the mental and emotional resilience to cope with those changes.
A psychological evaluation will assess:
- The patient’s understanding of the procedure and its risks
- The patient’s ability to follow post-operative guidelines
- The presence of any mental health issues that might affect recovery or long-term success, such as depression or eating disorders
6. Consultation with a Bariatric Surgeon
Before approving surgery, Cigna also requires that patients consult with a board-certified bariatric surgeon. The surgeon will review the patient’s medical history, discuss the types of bariatric surgery available, and determine if the patient is a good candidate for surgery. The surgeon may recommend additional tests, such as blood work, imaging, or a sleep study, to ensure that the patient is healthy enough for surgery.
Cigna’s Pre-Authorization Process
Once a patient meets all of the eligibility requirements, they must go through Cigna’s pre-authorization process. This process ensures that the surgery is approved for coverage under the patient’s health plan. Below are the steps involved in the pre-authorization process.
1. Submission of Medical Documentation
The bariatric surgeon and healthcare team will gather all necessary medical documentation. This includes:
- Records of the patient’s BMI and obesity-related health conditions
- Documentation of previous weight loss attempts and participation in a supervised weight management program
- Results of the psychological evaluation
- Any additional test results, such as lab work or imaging
2. Review by Cigna
Once the medical documentation is submitted, Cigna’s team of medical professionals will review the information to determine if the patient meets the criteria for bariatric surgery. The review process typically takes several weeks.
3. Approval or Denial
If the patient meets all of Cigna’s requirements, the surgery will be approved. However, if any criteria are not met, the surgery may be denied. In this case, the patient can appeal the decision or work with their healthcare provider to address any issues.
See Also: Does The VA Do Weight Loss Surgery
Post-Surgery Requirements
Cigna also has post-surgery requirements to ensure long-term success. After bariatric surgery, patients must commit to follow-up care, which includes:
1. Regular Medical Check-Ups
Patients will need to have regular check-ups with their surgeon and primary care doctor to monitor their progress. These appointments help ensure that the patient is losing weight in a healthy manner and that there are no complications.
2. Nutritional Counseling
Cigna may require patients to work with a nutritionist after surgery to learn how to maintain a healthy diet. Nutritional counseling is crucial because bariatric surgery alters how the body processes food, and patients need to adjust their eating habits to avoid complications and ensure long-term success.
3. Psychological Support
Patients may also need ongoing psychological support to help them adjust to the physical and emotional changes after surgery. Bariatric surgery can have a significant impact on a person’s self-image, relationships, and mental health, so ongoing support is important for maintaining overall well-being.
4. Physical Activity
Patients are encouraged to incorporate physical activity into their daily routine to enhance weight loss and improve overall health. While exercise is not the sole factor in weight loss after bariatric surgery, it plays an important role in maintaining a healthy lifestyle and preventing future weight gain.
Conclusion
Cigna’s requirements for bariatric surgery are in place to ensure that patients are good candidates for the procedure and have the best chance of success. These requirements include meeting specific BMI criteria, documenting previous weight loss efforts, undergoing a psychological evaluation, and working with a bariatric surgeon. By meeting these requirements and committing to the necessary lifestyle changes, patients can achieve long-term weight loss and improved health.
Bariatric surgery is a serious decision, but for many people, it is a vital step toward a healthier life. If you are considering bariatric surgery and have Cigna insurance, understanding these requirements is the first step in your weight loss journey.
