Your SilverSummit Healthplan and Bariatric Surgery

If you have a SilverSummit Healthplan, you may have insurance coverage for certain bariatric procedures when strict clinical and pre-surgical requirements are satisfied. Whether you’re considering your first surgery or a revision of a prior one, knowing the eligibility guidelines can help you prepare, avoid delays, and prevent unexpected costs.

Who Qualifies for Bariatric Surgery?

SilverSummit considers bariatric surgery medically necessary when specific conditions are satisfied. These include both your medical history and a complete pre-surgical evaluation.

Adults (18 and older)

Eligibility is based on your BMI and the presence of related health issues:

• BMI of 35 or higher with or without weight-related medical conditions, depending on the type of surgery (or 32.5 or higher for individuals of South Asian, Southeast Asian, or East Asian descent)
• BMI between 30 and 35 (or 27.5 to 32.5 for Asian populations) with one or more obesity-related conditions, such as, but not limited to:
  • Type 2 diabetes
  • High blood pressure
  • Sleep apnea
  • Heart disease
  • Liver disease
  • Polycystic ovarian syndrome (PCOS)
  • Infertility

Adolescents (Under 18)

Minors may qualify for certain procedures (like sleeve gastrectomy or gastric bypass) if they meet age-appropriate BMI thresholds and have severe, uncontrolled obesity-related conditions. SilverSummit lists the following criteria:

• BMI of 40 or more

OR

• BMI of 35 or more with a serious weight-related health issue that hasn’t improved with medical treatment, such as:
  • Type 2 diabetes
  • Obstructive sleep apnea
  • Gastroesophageal reflux disease (GERD)
  • Fatty liver disease
  • Orthopedic conditions like Blount’s disease or Slipped Capital Femoral Epiphysis (SCFE)

What’s Required Before Surgery?

Within six months of the scheduled procedure, several evaluations are needed:

• A medical clearance from a primary care provider, or a cardiologist/pulmonologist if there are heart or lung concerns.
• A nutritional assessment with a qualified healthcare provider.
• A mental health evaluation to confirm that the patient is a good candidate and that any existing concerns are well-managed.

Repeat or Revision Surgeries

SilverSummit may cover repeat or conversion surgeries under certain circumstances, such as:

• To fix complications from a previous bariatric procedure
• If the first surgery didn’t result in adequate weight loss
• When a procedure needs to be converted (e.g., from a gastric band to a sleeve gastrectomy or bypass)
• When GERD symptoms persist after a prior procedure and medications haven’t worked
• When a second-stage surgery is needed for those with a BMI ≥ 50

To qualify for revision, all original criteria must be met again, along with documentation of why the first procedure was unsuccessful and proof of adherence to post-surgery care.

What’s Not Covered?

SilverSummit does not consider the following procedures medically necessary, based on limited evidence of safety or long-term effectiveness:

• Mini gastric bypass (one-anastomosis bypass)
• Gastric balloons (e.g., Orbera, Obalon)
• Stomach aspiration devices (like AspireAssist)
• Vagus nerve blocking therapy
• Gastric electrical stimulation
• Vertical banded gastroplasty
• Endoscopic sleeve procedures
• And several other experimental or less-established techniques

Where Do You Begin?

If you’re considering bariatric surgery under SilverSummit Healthplan, here’s how to start:

• Confirm your BMI and relevant medical history with your healthcare provider
• Complete all preoperative clearances and evaluations within six months of surgery
• Work closely with your care team to gather and submit the required documentation
• Make sure the procedure you’re pursuing is one of the covered options

Need help gathering your records or preparing your documentation? The team at VIPSurg can walk you through the process and answer any questions you may have along the way.