Does Cigna Alabama Cover Bariatric & Metabolic Surgery?
Cigna offers a range of options, both through employer coverage plans and private plans, for individuals, families, and medicare. The Surgical Association of Mobile providers are considered in-network for most of these plans. Providers considered to be in network are able to offer a lower out of pocket expense than providers that are out of network. We understand that insurance language and policies can be confusing. Our team is always happy to help you better understand your benefits and coverage for any procedure we offer. Weight loss surgery often requires careful compliance to receive coverage, with detailed documentation. It helps to have experts like the SAMPA team to help you navigate what is required for coverage.
Will My Cigna Insurance Policy Cover Weight Loss Surgery?
The first thing to consider when evaluating your Cigna plan for obesity treatment and bariatric surgery is what is covered and what, if anything, is excluded in your policy. You can contact Cigna of Alabama directly, typically through a phone number on the reverse side of your insurance card, or speak with the Human Resources department if the plan is offered through your employer. The exclusions section of the policy should indicate if bariatric surgery or obesity treatment is not a covered benefit of your plan. This is not typical, but does occur in some policies. When weight loss surgery is a covered benefit by your policy, there will usually be a detailed section explaining exactly what is and is not covered in terms of bariatric procedures and obesity treatment. Please note, policies are unique and can vary widely between plans and groups. You should not rely on information outside of what is stated in your specific policy. We encourage all interested patients to contact both Cigna Alabama and our office to learn more about coverage for weight loss surgery and to verify your benefits and eligibility. This is part of our intake process with every bariatric patient.
What Will My Out of Pocket Expenses Be?
What each patient’s financial responsibility will look like can vary greatly. Coverage will depend on your exact benefits and policy structure. For some patients, factors like other medical expenses you have incurred in the calendar year leading up to surgery can impact the exact out of pocket expense related to your procedure. Coverage for a particular treatment does not typically indicate that there will be no out of pocket expense to the patient. If you have a coinsurance or deductible on your policy, you will be responsible for paying that amount. We always encourage patients to call their insurance provider directly using the phone number on the back of your insurance card or speak with your employer’s benefits manager to better understand your policy and how your financial responsibility is structured. We will always strive to be transparent with you throughout the process to ensure you understand the financial commitment you are making. At your bariatric consultation, our Bariatric Coordinator will spend time with you reviewing your benefits and responsibilities, including what cost may be incurred.
Please be mindful that factors such as your personal deductible, family deductible and any set out of pocket max may factor in with the timing of your procedure scheduling and the ultimate cost of your procedure. Most plans that have deductibles, co-insurances and out of pocket maximums will reset with the calendar year. As we approach the end of the year, the actual out of pocket expenses for surgery may be lower if you have already paid for other medical expenses earlier in the same year. It is important to remember that the workup process typically requires several appointments, tests, and clearances to be completed. This process takes time and surgery schedules also tend to fill up towards the end of the calendar year. We recommend planning several months ahead and beginning the process early, especially if you plan to take advantage of specific timing.
What Are the Requirements for Coverage Of Weight Loss Surgery?
What is required for bariatric surgery coverage will vary slightly between individual plans. Generally, guidelines for pre-approval of bariatric surgery are standard. However, specific requirements may be unique to your policy and should always be verified:
- A patient’s body mass index, or BMI, should be 40 or greater, or should be 35 or greater with one or more associated medical conditions. This is typically the base requirement for bariatric surgery candidates. The qualifying “associated diseases” are typically listed in the policy description and may include type 2 diabetes, high blood pressure, obstructive sleep apnea (OSA) or others.
- A diagnosis of morbid obesity is often required to be documented in the patient’s medical records prior to surgery. Your primary care provider may also attest to the fact or dated photographs may be accepted in the case that morbid obesity has not been documented in the medical record.
- Supervised Weight Loss Programs are sometimes included in policy guidelines. Some policies will require documentation of physician supervised weight loss attempts over the past 3, 6, or even 12 months while others do not include this requirement. Some policies may seek documentation of participation in non-surgical weight loss programs such as Weight Watchers or personal training programs. We advise patients to speak with their insurance carrier directly on what documentation will and will not be accepted.
- Smoking Cessation is required at least eight weeks prior to surgery.
What Bariatric Procedures Does Cigna Alabama Cover?
Cigna of Alabama covers several bariatric procedures, including the gastric sleeve or sleeve gastrectomy, the roux-en-y gastric bypass, and duodenal switch. These procedures are commonly performed by the surgeons at Surgical Association of Mobile and have proven to be safe and effective procedures. Some patients may be good candidates for Lap-Band or gastric band surgery. This procedure may also be covered by insurance. At your first consultation, your surgeon will discuss the procedure options available in detail and the pros and cons of each. What is the best option for one patient, may not be the best for another. You are unique, as are your medical needs and goals.
Cigna of Alabama does not cover all weight loss procedures. Uncovered procedures include the intragastric balloon, Lap-Band for lower BMI patients, and any surgeries currently consider to be experimental like the Mini Gastric Bypass.
For patients who had a bariatric procedure performed in the past that was not ultimately successful, Cigna may cover a revision bariatric surgery. In this circumstance, documentation in the medical record is usually required to show the cause of failure is not a lifestyle consideration, meaning the regain or inadequate weight loss is not do to poor eating habits and lack of physical activity. Coverage for secondary or revisional weight loss surgery may require additional documentation. If you are interested in pursuing a revision weight loss surgery, please contact our office.
My Cigna Plan has a Bariatric Exclusion… What Do I Do?
Although bariatric surgery has proven successful over the years for improving patients overall health, not all insurance plans will include weight loss surgery in their covered procedures. Fortunately, the team at Surgical Association of Mobile has been able to create a competitive self-pay program to extend options to those without coverage available or who want to avoid unnecessary restrictions or burdens placed on the process by their policy. We are connected with trusted third party financing options to assist patients choosing to self-pay for surgery or those with large deductible policies. We invite you to contact our team to discuss your options and how we can help. You may also have options of coverage through a spouse or partner where coverage would differ or discussing the policy with your employer’s benefits manager may be worthwhile if a policy may be altered for the coming year or changes can be made during open enrollment.
How do I Contact Cigna?
Cigna can be contacted by telephone or through their website. Specific contact numbers may be different depending on the type of plan you have. You should reference the number on the back of your insurance card to reach the correct department. For other contact options reference Cigna online: https://www.cigna.com/