Does United Health Care Cover Bariatric Surgery?

Yes! United Health Care does cover some bariatric surgeries for eligible individuals. Determining what types of surgeries are protected by United Health Care and the appropriate next steps toward eligibility is crucial to a successful bariatric surgery outcome.

Bariatric surgery is an option for individuals who have been unsuccessful with other weight loss strategies like diet and exercise or even weight loss medications and are now experiencing some of the many adverse health side effects of obesity. The journey to better health through bariatric surgery starts with understanding the coverage provided by your healthcare insurer.

United Healthcare Bariatric Surgery Requirements

Like most insurers, United Health Care has detailed eligibility requirements for bariatric surgeries. Knowing these eligibility requirements well in advance can help you work with your bariatric center professionals to develop a successful action plan.

UHC eligibility requirements for adults vary from plan to plan and may include (please verify this with UHC):

• Must be 18 or older.
• The procedure must be for treating obesity (specific codes apply).
• Body Mass Index (BMI) of 40 or higher.
• BMI of 35 or higher and a documented history of cardiomyopathy, cardiovascular disease, type 2 diabetes, obstructive sleep apnea, or coronary artery disease with surgical intervention. These may vary between plans.
• Preoperative evaluation, including a detailed weight, dietary, and exercise history.
• Psychosocial-behavioral evaluation to identify any risk factors or post-surgery challenges that might impede a successful outcome and ensure good candidacy for surgery.
• Participation in a multidisciplinary surgical preparatory regimen may sometimes replace the preoperative and psychosocial-behavioral evaluations.
• Some plans may require monthly weigh-ins.

UHC eligibility requirements for adolescents (12-17 years) may include (please verify this with UHC):

• Body Mass Index (BMI) of 40 or higher
• BMI of 35 or higher and a documented history of type 2 diabetes, poorly controlled hypertension, or obstructive sleep apnea
• An evaluation at a multidisciplinary center accredited by the Metabolic and
• Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) or a center with demonstrated similar program components.
• Proof of full skeletal maturity.

While these are general United Health Care eligibility requirements, each plan is unique and may have different or additional needs. Plan benefits and requirements may change over time, and you should check your plan each calendar year upon renewal.

Types of Bariatric Surgeries Covered by United Healthcare

United Health Care covers many bariatric surgeries, but not all. However, the most common procedures outlined below are generally covered by UHC with proper eligibility:

• Biliopancreatic diversion/biliopancreatic diversion with duodenal switch.
• Gastric bypass.
• Adjustable gastric banding (Adults, age 18 or older).
• Gastric Sleeve / Sleeve Gastrectomy.
• Vertical banded gastroplasty.
• Revisional surgeries may also be covered when considered medically necessary.

Certain procedures considered experimental, in addition to gastric balloon, endoscopic sleeve, and SADI (Single Anastomosis Duodeno-Ileostomy), may not be covered. Some plans only allow for 1 surgery per lifetime.

Deductibles, Co-Pays, and Other Out-of-Pocket Expenses

Even with eligibility and UHC coverage, your bariatric surgery will have some out-of-pocket costs. The amount depends on several provisions in your policy, including:

Deductibles

There are typically two deductibles in your health insurance plan: the individual and family deductibles, both of which reset annually. You must meet your annual individual deductible (pay that much out-of-pocket) unless the family deductible has been completed in the contract year.

Co-Insurance

Even once your deductible has been met, co-insurance may apply. This means you may share the cost of surgery with UHC up to your out-of-pocket max. Your co-insurance percentage is usually much lower than UHC’s, but the exact rate varies with each plan.

In-Network or Out-of-Network

United Health Care has a network of preferred health professionals. You can choose a healthcare provider in or out of the UHC network, but you will likely pay a higher co-insurance percentage if you choose an out-of-network option.

Deductibles, co-insurance, and out-of-network costs are everyday out-of-pocket expenses for all insurance providers. However, the amounts differ between insurers and plans, so check your policy or call United Health Care customer service.

How to Appeal a United Health Care Denial of Bariatric Coverage

You’ve completed all the steps and are excited about the lifestyle changes that await – but you’ve received a denial of coverage from United Health Care. What do you do now?

First, don’t give up hope. Many denials result from a missing document, incorrect medical coding, or some other small matter that can quickly be resolved with a phone call. Start by calling your surgeon’s office to get assistance in determining if the problem can be corrected.

Your bariatric surgery center can often be an excellent resource when you receive a denial. They have years of experience and can guide the problem to resolution.

When that doesn’t work, it’s time to file an appeal. Appeals exist for this reason. Be ready to make your medical case and provide the necessary documents with the assistance of your surgeon’s office.

Working Together for Bariatric Surgery Success

Whether you are at the beginning of your journey, trying to determine if bariatric surgery is right for you, or you’ve completed all the steps and are now facing an appeals process, you don’t have to go it alone.

Your bariatric center professionals have the experience needed and desire for success to guide you throughout your wellness journey.