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Cigna and Bariatric Surgery: What You Should Know Before You Begin

Doctor with a stethoscope writing something on a piece of paper

If you’re considering weight loss surgery, understanding your insurance coverage is an important first step. Cigna is a major health insurance provider offering a range of plans that may cover bariatric surgery when certain medical and clinical criteria are met. Whether you’re covered through an employer-sponsored plan, an individual policy, or through the healthcare marketplace, knowing what Cigna requires can help you move forward and eliminate financial surprises.

Does Cigna Cover Weight Loss Surgery?

Yes – certain plans will cover bariatric surgery for adults and adolescents who meet certain criteria. These include a qualifying body mass index (BMI) and the presence of certain obesity-related health conditions. Cigna outlines eligibility as follows: a BMI of 40 or higher; a BMI of 35-39 with specific comorbidities such as diabetes, high blood pressure, sleep apnea, GERD, or fatty liver disease; a psychological clearance from a mental health professional; a nutritional assessment; evidence that previous medical weight loss efforts have failed; and details about the proposed procedure from your surgeon. For individuals of Asian descent, the BMI thresholds are adjusted to greater than 37 or greater than 32 with co-existing conditions like the ones previously mentioned. Cigna also requires that all evaluations take place within the preceding 12 months.

Some of these requirements will vary based on age, and your particular policy will outline those differences.

Which Procedures Are Covered?

Once the pre-qualifications are met, Cigna considers a range of surgical options medically necessary. Approved procedures include gastric sleeve, Roux-en-Y gastric bypass, duodenal switch, single-anastomosis duodenal-ileal bypass with sleeve gastrectomy, vertical banded gastroplasty, and adjustable silicone gastric banding. Your plan may also outline additional types of surgeries that are not covered, including experimental or investigational procedures. Also, revisions due solely to noncompliance with post-op instructions will not be covered so be sure to follow all of your healthcare provider’s instructions and make the necessary lifestyle changes.

Adjustments to gastric bands and revisional surgeries may also be covered when there are complications, such as slippage, obstruction, or failure to lose weight, provided that compliance and all other eligibility requirements are met.

Does Cigna Have Provider or Facility Requirements?

Yes. Cigna has identified designated bariatric treatment facilities – a 3 Star Quality designation and the Center of Excellence (COE) designation – that can be found in their provider directory. Choosing a designated center may be required by your plan and can also help minimize out-of-pocket costs. Coordinate with your healthcare team and a Cigna representative to be sure you are choosing in-network providers and facilities.

Are There Other Details to Consider?

Cigna requires preauthorization for bariatric surgery. This means your healthcare provider must submit documentation supporting the medical necessity of the procedure in order for the surgery to be approved for insurance coverage. Commonly required materials include clinical records and exam notes, imaging and lab reports, documentation of unsuccessful weight loss attempts that were overseen by a healthcare provider, letters of medical necessity from your provider(s), psychological evaluation, and nutritional counseling. Your healthcare administration team can help collect and submit these documents, but it’s smart to confirm submission status with Cigna directly or via your member portal.

Note that failing to obtain prior authorization could result in claim denial or increased out-of-pocket costs so be sure not to skip this step.

What Can You Expect to Pay Out-of-Pocket?

Even if your plan covers the proposed procedure, you may still encounter out-of-pocket (OOP) expenses. OOP costs will vary depending on the type of plan you have with Cigna, but some typical ones include meeting your deductible, paying a copay or coinsurance, penalties for utilizing out-of-network providers or facilities, or pre- and post-operative care not included in the policy. These details are typically outlined in the “Explanation of Benefits” (EOB) section of your policy, so be sure to review that section and talk to the billing team to get a clear estimate ahead of time.

It isn’t unusual for a claim to be denied on the first pass. If this happens, it is possible that further documentation needs to be provided or that a step was skipped. If your claim is denied, our team can assist you in navigating the appeal process.

If using insurance benefits is not an option, that isn’t the end of the line. For those who do not receive insurance approval, VIPSurg offers a competitive cash pay rate starting at $9,750 for patients interested in the gastric sleeve, which you can learn more about here. Other options include talking to your HR representative about using health savings plan (HSA) funds or doing some research on medical loan options.

Let’s Recap a Basic To-Do List

Here’s how to prepare for your bariatric surgery with Cigna:

  • Call Cigna or log in to your member portal to confirm your eligibility and benefits.
  • Choose a provider within Cigna’s designated bariatric center directory.
  • Make sure all prior authorizations and evaluations are submitted on time.
  • Talk to your clinic administration team about expected costs and payment options.
  • Keep records of all communications with Cigna and your providers.

Still Have Questions?

We have extensive experience working with insurance and can help you every step of the way – from verifying benefits to submitting documentation and answering billing questions. If you’re unsure about what’s covered or how to start, reach out to our team. We’re here to help!