Tool: Check Your Weight Loss Surgery Insurance – United Healthcare

Your United Healthcare weight loss surgery insurance coverage depends on several factors, all of which are reviewed below. First, use our free insurance check tool to quickly double check your plan:

List of United Healthcare Insurance Companies

United Healthcare’s policy on weight loss surgery also applies to their subsidiary insurance companies, including:

The following sections will explain all you need to know about United Healthcare weight loss surgery coverage:

TABLE OF CONTENTS

Click on any of the topics below to jump directly to that section

  1. Coverage Requirements
  2. Coverage Plans
  3. Covered Procedures
  4. Appealing a Denial
  5. Find a Weight Loss Surgeon
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01.

Coverage Requirements

SECTION SUMMARY:

  • 35+ Body Mass Index (BMI)
  • Documentation of failed diet attempts
  • Psychological evaluation

READ THIS FIRST

Even if your insurance company covers bariatric surgery in some plans, that does not mean that your specific plan covers it. The obesity surgery approval requirements in this section assume that weight loss surgery is covered by your specific policy.

To confirm whether your specific policy covers bariatric surgery, click here to contact a surgeon and ask for a free insurance check.

Disclaimer: The information contained on this page may not include all components of your insurance company’s medical policy and/or may not be up to date. Contact your insurance company to confirm all benefits.

In order to be approved by United Healthcare for bariatric surgery in the United States, you must meet the following criteria:

  1. Diagnosis of Morbid obesity, defined as
    • BMI greater than 40

    Or

    • BMI 35 – 39.9 AND one of the following
      • Type 2 diabetes
      • Cardiovascular disease
      • History of coronary artery disease with a surgical intervention such as cardiopulmonary bypass or percutaneous transluminal coronary angioplasty
      • Cardiopulmonary problems
      • History of cardiomyopathy

    Use this BMI Calculator to check your body mass index:

  2. Documentation of a motivated attempt of weight loss through a structured diet program, prior to bariatric surgery, which includes physician or other health care provider notes and/or diet or weight loss logs from a structured weight loss program for a minimum of 6 months.
  3. Psychological evaluation to rule out major mental health disorders which would contraindicate surgery and determine patient compliance with post-operative follow-up care and dietary guidelines

Weight Loss Surgery Criteria for Fully Insured Group Policies in Maryland ONLY

  1. A Body Mass Index (BMI) above 40 without comorbidity; OR
  2. A BMI of 35 or greater with obesity related comorbid medical conditions including:
    • Hypertension
    • Cardiopulmonary condition
    • Sleep apnea
    • Diabetes
    • Any life threatening or serious medical condition that is weight induced
  3. Demonstration that dietary attempts at weight control have been ineffective through completion of a structured diet program, such as Weight Watchers or Jenny Craig. Either of the following in the two year period that immediately precedes the request for the surgical treatment of morbid obesity meets the indication:
    • One structured diet program for six consecutive months; or
    • Two structured diet programs for three consecutive months.
  4. Completion of a psychological examination of the member’s readiness and fitness for surgery and the necessary postoperative lifestyle changes

Additionally, as stated in the Code of Maryland Regulations: Coverage of surgical treatment of morbid obesity is limited to adults 18 years of age or older.

Adolescents Requirements

Some bariatric surgical procedures are proven in adolescents for the treatment of clinically severe obesity as defined by the criteria above and who have:

  1. Achieved greater than 95% of estimated adult height based on documented individual growth pattern
  2. A minimum Tanner stage of 4

Definition: Tanner Stage

A stage of puberty in the Tanner growth chart, based on pubic hair growth, development of genitalia in boys, and breast development in girls (1).

Revision Requirements

Surgical revision or a second bariatric surgery could be deemed medically necessary for inadequate weight loss if the original criteria for bariatric surgery (BMI, comorbidities and patient selection criteria) continue to be met.

If Your Policy Does NOT Cover It: Seek Partial Coverage

You may be able to get part of the costs paid for by insurance even if weight loss surgery isn’t covered. It’s all about how your doctor and hospital submit your claims to your insurance company.

For example, there are many non-bariatric surgery reasons for your doctor to recommend:

  • Cardiology exam
  • Lab work
  • Medically supervised diet program
  • Psychological exam
  • Sleep study

These are ordered for many reasons other than bariatric surgery and may be covered as a result. If your doctor submits one of these claims using a weight loss surgery CPT code (Current Procedural Terminology Code), your insurance is unlikely to cover it. But if your doctor uses a general CPT code, it probably will be covered.

While this may sound “sneaky”, it is an ethical practice. After all, these tests will be beneficial regardless of whether you move forward with surgery.

Contact United Healthcare to Ask About Bariatric Surgery

02.

Coverage by Plan Type

SECTION SUMMARY:

  • Coverage Through Your Employer
  • Individual & Family Plans
  • Medicare

Before getting into the types of insurance plans, you can cut to the chase by contacting a local bariatric surgeon’s office. Most surgeons will contact your insurance company for free to confirm whether or not you’re covered.

Click here to find a local surgeon and ask them to check your insurance for you for free.

United Healthcare does cover weight loss surgery, but your specific policy must include it in order for you get it covered.

Following are a list of United Healthcare plan types and whether they cover bariatric surgery:

Weight Loss Surgery for Health Plans Through Your Work

If you work for a company that has 50 or more full time employees, it is completely up to your employer to decide whether or not to cover bariatric surgery under your health plan.

To find out whether weight loss surgery is covered by your employer’s plan, you have a few options:

Weight Loss Surgery for Individual/Family Plans

The Affordable Care Act (Obamacare) requires all individual and small group plans (less than 50 full time employees) to include weight loss surgery coverage as long as it is considered an “Essential Health Benefit” in your state.

The following states DO currently consider bariatric surgery an Essential Health Benefit (bariatric surgery is covered by all individual, family and small group plans in these states):

Your State Not on the List?

If your state is NOT on the list, then weight loss surgery is probably NOT covered under your plan.

First, contact your local surgeon to be sure. For no charge, their office will contact your insurance company on your behalf to work through the details.

If your surgeon confirms that your policy does not include obesity surgery, you still have several options for making surgery more affordable. See these pages for more information:

    • Arizona
    • California
    • Delaware
    • Hawaii
    • Illinois
    • Iowa
    • Maine
    • Maryland
    • Massachusetts
    • Michigan
    • Nevada
    • New Hampshire
    • New Jersey
    • New Mexico
    • New York
    • North Carolina
    • North Dakota
    • Oklahoma
    • Rhode Island
    • South Dakota
    • Vermont
    • West Virginia
    • Wyoming

Regardless of whether your state is on the list, contact a qualified surgeon to request a free insurance check to verify your coverage.

To review your insurance company’s obesity surgery coverage requirements, click here to jump back up the page.

Weight Loss Surgery for Medicare Plans

All Medicare plans are required to cover the following weight loss surgery procedures:

However, special Medicare-specific criteria apply. Click here to learn more about Medicare bariatric surgery coverage.

03.

Covered Weight Loss Procedures

SECTION SUMMARY:

  • Gastric Sleeve
  • Gastric Bypass
  • Lap-Band
  • Duodenal Switch
  • Vertical Banded Gastroplasty
  • Biliopancreatic bypass (Scopinaro procedure)

Please see below for the procedures United Healthcare covers, might cover under certain circumstances, and those that are not covered under any circumstances:

Procedures That ARE Covered

For Adults

For Adolescents

Procedures That Are NOT Covered

The following procedures are NOT covered by United Healthcare:

  • Gastric Balloon
  • vBloc Therapy
  • AspireAssist
  • Mini Gastric Bypass
  • Gastrointestinal liners (EndoBarrier)
  • Transoral endoscopic surgery (such as transoral gastroplasty (TOGA)
  • Restorative Obesity Surgery
  • Endoluminal (ROSE) procedure
  • Gastric electrical stimulation with an implantable gastric stimulator (IGS)
  • Laparoscopic greater curvature plication, also known as total gastric vertical plication
  • Bariatric surgery to treat gynecological abnormalities, osteoarthritis, gallstones, urinary stress incontinence or as a treatment for gastro-esophageal reflux (including for Barrett’s esophagus or gastroparesis), and other obesity associated diseases that generally do not lead to life threatening consequences
04.

Appealing a Denial

SECTION SUMMARY:

  • General Appeal Instructions
  • Appeal Details Specific to United Healthcare

If United Healthcare denies your weight loss surgery claim and you think it should be covered, consider filing an appeal.

Our Health Insurance Appeals page will get you started, then head over to the Disputes & Appeals page for United Healthcare to learn how to proceed.

05.

Find a Weight Loss Surgeon

SECTION SUMMARY:

  • Ask for a free insurance check or cost quote
  • Attend a free seminar or webinar
  • Schedule a phone or in-person consultation (both often free)
  • Ask for a free insurance check or cost quote

  • Attend a free seminar or webinar

  • Schedule a phone or in-person consultation (both often free)

Search the weight loss surgeon directory below to ask a surgeon about a free insurance check by country and region:

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