Weight loss surgery, also known as bariatric surgery, is an important medical treatment for people who struggle with severe obesity. Many individuals facing health challenges due to obesity are interested in whether their insurance covers the cost of surgery. If you are insured by Humana, a major health insurance company in the United States, you may be wondering whether they will pay for weight loss surgery. In this article, we will explore the criteria Humana uses, what types of surgeries are covered, and what steps you need to take if you’re considering bariatric surgery.
Understanding Weight Loss Surgery
Before diving into Humana’s coverage policies, let’s first understand what weight loss surgery is. Bariatric surgery is a group of procedures designed to help individuals lose weight by making changes to the digestive system. The most common types include:
Gastric Bypass: This surgery involves creating a small pouch at the top of the stomach and connecting it directly to the small intestine. It limits how much you can eat and reduces the absorption of calories and nutrients.
Gastric Sleeve: A large portion of the stomach is removed, leaving a smaller, tube-shaped stomach. This reduces the amount of food you can eat and helps control hunger hormones.
Adjustable Gastric Band: An inflatable band is placed around the upper part of the stomach to create a smaller stomach pouch. This can be adjusted over time to change the size of the pouch.
Duodenal Switch: This procedure involves a more significant bypass of the small intestine, combining both restrictive and malabsorptive elements to limit food intake and reduce absorption.
These surgeries are usually recommended when diet and exercise alone have not been successful in achieving significant weight loss and when obesity poses serious health risks such as Type 2 diabetes, high blood pressure, or heart disease.
Humana’s Coverage for Weight Loss Surgery
Humana does offer coverage for weight loss surgery, but it is important to note that this coverage is not automatically included in all of their insurance plans. Coverage for bariatric surgery often depends on the specific plan you have and whether you meet certain medical criteria.
Types of Plans That May Cover Weight Loss Surgery
Humana provides a variety of health insurance plans, including employer-sponsored plans, individual and family plans, and Medicare Advantage plans. Coverage for bariatric surgery is typically found in more comprehensive plans, such as:
Employer-Sponsored Health Plans: Many employer-sponsored Humana plans offer coverage for weight loss surgery. However, this is not guaranteed, and you will need to check your specific plan’s benefits.
Individual and Family Plans: Some individual and family Humana plans may cover weight loss surgery, but like employer-sponsored plans, coverage varies.
Medicare Advantage Plans: If you are covered by a Humana Medicare Advantage plan, you may have coverage for weight loss surgery. However, you must meet Medicare’s specific criteria for bariatric surgery.
Medical Necessity
Humana, like most insurance companies, typically covers weight loss surgery only if it is deemed medically necessary. This means that the surgery must be considered essential to treat a medical condition that could worsen without it. In general, to qualify for coverage under Humana, you must meet the following criteria:
Body Mass Index (BMI) Requirements: You will usually need to have a BMI of 40 or higher, or a BMI of 35 or higher with at least one obesity-related health condition, such as Type 2 diabetes, high blood pressure, or sleep apnea.
Documented Weight Loss Attempts: Most insurance plans, including those from Humana, require that you provide proof of previous weight loss attempts. This might involve participation in a medically supervised weight loss program, which could last for several months.
Health Evaluation: Humana may require you to undergo a thorough medical evaluation to ensure that you are a good candidate for bariatric surgery. This could involve consultations with specialists, such as a bariatric surgeon, a dietitian, or a psychologist, to assess your readiness for the surgery and your ability to maintain lifestyle changes afterward.
What Types of Bariatric Surgery Are Covered by Humana?
Humana typically covers the most common types of weight loss surgery if you meet the eligibility requirements. These may include:
- Gastric Bypass
- Gastric Sleeve
- Adjustable Gastric Band
- Duodenal Switch
However, the specific procedures covered by your plan can vary, so it is essential to check with Humana to determine what is included in your policy.
Steps to Get Humana to Cover Weight Loss Surgery
If you believe you qualify for weight loss surgery and are covered by Humana, there are several steps you need to follow to get approval for the procedure:
1. Review Your Insurance Policy
The first step is to carefully review your Humana insurance policy or contact their customer service department to find out whether your plan includes coverage for bariatric surgery. Ask specifically about the types of procedures covered, the eligibility criteria, and any out-of-pocket costs you may be responsible for, such as deductibles or co-pays.
2. Get a Referral from Your Primary Care Doctor
Most insurance companies, including Humana, require a referral from your primary care doctor before approving bariatric surgery. Your doctor will assess your medical condition, discuss your weight loss history, and recommend the surgery if they believe it is appropriate. This referral will be a key part of your insurance approval process.
3. Participate in a Medically Supervised Weight Loss Program
Humana, like many insurers, may require you to participate in a medically supervised weight loss program for a specific period, typically three to six months. This program allows you to demonstrate that you have attempted to lose weight through traditional means, such as diet and exercise, before pursuing surgery. The program might include regular visits with a dietitian, a doctor, or a weight loss specialist.
4. Complete Required Medical Evaluations
You will need to undergo a series of medical evaluations to determine your suitability for bariatric surgery. These evaluations may include:
Nutritional Assessment: A dietitian may assess your current eating habits and provide guidance on post-surgery nutrition.
Psychological Evaluation: Many insurance plans require a psychological evaluation to ensure that you are mentally and emotionally prepared for the lifestyle changes that come with bariatric surgery.
Pre-Operative Testing: You may also need to undergo various medical tests, such as blood tests, an electrocardiogram (EKG), or a sleep study, to ensure that you are healthy enough to undergo surgery.
5. Submit Documentation to Humana
Once you have completed the required evaluations and obtained the necessary referrals, your bariatric surgeon or primary care doctor will submit the documentation to Humana for approval. The insurance company will review your case to determine whether you meet the medical necessity criteria and whether the surgery is covered under your plan.
See Also: What Private Health Insurance Covers Weight Loss Surgery
What to Expect After Surgery
If Humana approves your weight loss surgery, you can expect to go through several stages of recovery. Most patients lose significant weight in the months following surgery, but you will need to follow a strict post-surgery diet and make lifestyle changes to maintain the weight loss. Humana may also cover some post-surgery care, such as follow-up appointments, nutritional counseling, and support groups.
Potential Costs Not Covered by Humana
Even if Humana approves your weight loss surgery, you may still be responsible for certain costs. These can include:
Deductibles: The amount you must pay out-of-pocket before your insurance begins covering the procedure.
Co-Pays or Co-Insurance: You may be required to pay a percentage of the total cost of the surgery or a fixed co-pay amount.
Additional Fees: Some services, such as cosmetic procedures or specialized nutritional supplements, may not be covered by your insurance.
Conclusion
Humana does provide coverage for weight loss surgery, but it is important to meet their specific medical criteria and follow the required steps for approval. If you are considering bariatric surgery, it’s essential to carefully review your insurance plan, consult with your doctor, and gather the necessary documentation. By taking these steps, you can increase your chances of having Humana pay for your weight loss surgery and improve your overall health.
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