Does UnitedHealthcare Nevada Cover Bariatric Surgery?
UnitedHealthCare (UHC) is one of the largest health insurance companies in North America, and for UHC members in Nevada, the answer is that coverage might be possible. But it is not always guaranteed. It depends significantly on two things: your insurance policy terms and whether specific medical criteria need to be met.
How Do I Know If My Policy Will Cover Surgery?
UHC generally offers coverage for bariatric surgery as a benefit, but this is dependent on your specific plan. Some plans do provide bariatric benefits, while others do not, particularly in situations where employers have opted out of offering weight-loss surgery. The only sure way to know if you’re covered is to either call UnitedHealthcare directly or log in to your member portal online and review the procedures, such as gastric sleeve or gastric bypass, that are included in your benefits. If you don’t see the details you’re looking for in your benefits package, be sure to reach out to UHC directly to better understand your coverages and exclusions. Also be sure to go over what your out-of-pocket (OOP) expenses may be.
How Will I Know If I Meet the Medical Criteria?
If your UHC plan covers bariatric surgery, the next step is to meet specific medical necessity requirements. The majority of patients are required to have a body mass index (BMI) of at least 40. However, individuals with a BMI between 35 and 39.9 may also meet the requirement if other conditions are present, such as type 2 diabetes, high blood pressure, sleep apnea, or acid reflux, to name a few. Along with your physician-verified BMI, it is usually expected that patients provide documentation of previous medically supervised attempts to lose weight. For example, this could involve participating in guided weight-loss programs that have been approved by your healthcare provider.
Typically, UnitedHealthcare asks patients to fulfill multiple other prerequisites before surgery will be approved. Your plan could require a psychological evaluation to guarantee preparation for any changes to your lifestyle post-surgery – emotional support is just as important as physical and financial support. Counseling in nutrition is another prerequisite to help patients understand the dietary adjustments they need to make in order to achieve long-term success. There are times when UHC may request several months of weight loss attempts—three to six months usually—through a pre-authorization process. Each document and visitation is recorded and submitted to establish your case for medical accuracy.
After these standards are met, the authorization process can proceed. Your care team at VIPSurg can assist you every step of the way, from verifying your plan benefits and collecting your medical records for document submission to direct communication with UnitedHealthcare. This process is often time-consuming. However, the support of a professional surgical center’s administrative team can help substantially by preventing delays or denials.
If you’re curious about whether UnitedHealthcare covers your revision surgery, the answer is not always straight forward. For initial surgery, procedures must align with the necessary guidelines and be performed by a certified surgeon at an approved medical facility. If you are needing to revisit a past surgery, such as the conversion of a gastric band to a gastric sleeve or a sleeve to a bypass, if there were evident complications of the initial surgery, or if the original surgery did not achieve significant weight loss, you may have provisions within your plan to rectify those issues.
What Can I Do If My Policy Does Not Cover Weight-Loss Surgery?
Unfortunately, it is possible for some patients not to be approved on the first attempt. Certainties for denials include unidentified documents, partial completion of psychological evaluations, lack of proof of efforts towards weight loss, or a BMI that is not within the limits. The facility where the revision surgery is performed is also a crucial factor; UnitedHealthcare requests that procedures be performed at a “Center of Excellence”. That isn’t the end of it though, if a claim is not approved, denials can likely be appealed, and your care team can help guide you through that process.
If after the denial and appeal process you still cannot gain coverage, you have other options. VIPSurg offers an excellent, cash pay rate starting at $9,750 for patients interested in the gastric sleeve. You can get more details about our gastric sleeve cash pay rate here. You also may be able to talk to your HR representative about health savings plans or a financial advisor about loan options.
At VIPSurg, we are aware of the stressors in navigating your insurance coverage. This is why our team is committed to supporting you throughout each step, from benefit verification and pre-operative preparation to submitting all necessary paperwork. We work diligently with your primary care physician, nutritionist, and psychologist to ensure everything is streamlined effectively.
If you’re ready to take the next step toward a healthier future, your first move is to call and schedule a consultation with our team. We will verify your UnitedHealthcare benefits, review your options for bariatric surgery, and assist you in obtaining approval. Our aim is not only to provide you with life-changing care, but also to ensure excellent care before, during, and long after your procedure.
