First Health Covers Weight Loss Surgery

First Health covers weight loss surgery. To qualify for coverage of weight loss surgery, your policy must include coverage. Please note that not all policies include coverage. So, to find out if your policy includes coverage, please talk directly to First Health.

A few years back, First Health merged with Coventry Health Care. There is no specific information available on First Health’s policy regarding bariatric surgery.

The following information is based on Coventry Health Care’s requirements.

First Health Pre-Approval Requirements

Weight loss surgery is an efficient cure for morbid obesity and First Health provides full coverage for bariatric procedures. For First Health to fully cover the procedure, the patient must fulfill the following requirements.

• The patient seeking coverage for bariatric surgery should be over 18 years of age at the time of applying.
• Patients applying for coverage for a bariatric surgery procedure should have a BMI of over 40, or over 35 along with at least one of the following co-morbid conditions:
  • Diabetes
  • Cardiovascular Disease
  • Sleep Apnea
  • Asthma
  • Joint Disease

Insurance plans generally require the patients to fulfill the following criteria as well.

• Prior to the surgery the patient needs to undergo strict psychological evaluation. The evaluation is aimed at determining whether or not the patient fully understands the surgery, is willing to go through with it, and mentally able to make the changes necessary for the surgery to be a success.
• Relevant documentation should be submitted stating that the patient attempted weight loss prior to the surgery which resulted in failure. Most insurance companies accept programs such as Jenny Craig, Weight Watchers, and other medically supervised weight loss programs. Some carriers even accept gym membership receipts as a valid attempt at weight loss.
• Documentation stating that bariatric surgery is the best option should be submitted. This is called a Letter of Medical Necessity. A letter of Medical Necessity is usually not accepted if written by your bariatric surgeon. It must come from another physician such as your primary care provider, OBGYN, etc. However, your bariatric surgeon can help you with this step.

Types of Weight Loss Surgeries Covered by First Health

If the patient meets the criteria mentioned above, the following types of surgical procedures are covered.

• Gastric Bypass
• Sleeve Gastrectomy
• Adjustable Gastric Banding
• Biliopancreatic Bypass with Duodenal Switch

The weight loss procedures that are generally qualified for coverage are the ones that have proven to be effective. While there are other procedures available, they are currently considered experimental and not covered.

Procedures Excluded from Coverage

Procedures that are not outlined above would not be covered under a First Health plan. Information about excluded procedures can be found on the First Health website.

Is a Second Weight Loss Surgery Covered If Lap Band DOESN’T Work?

Generally, the decision to cover a second weight loss surgery is made depending on the circumstances. Specific information relating to First Health’s policy regarding a second surgery is not available.

Revisions

A bariatric surgical procedure is subject to revision provided certain requirements are fulfilled. No specific information is available regarding a revision policy for First Health.

Does First Health Require a Center of Excellence?

Yes, First Health requires the surgery to be performed at an approved “Center of Excellence”.

Do I Have To Use An In-Network Bariatric Surgeon?

First Health is quite specific about the requirements for using an in-network surgeon. The patient will only be provided coverage if the surgical procedure is carried out by a surgeon approved by First Health prior to the surgery.

First Health Contact Info to Inquire About Surgery

First Health members can inquire about weight loss surgery at 1-800-226-5116.