United Healthcare’s Criteria For Weight Loss Surgery Coverage

While many United Healthcare Summary Plan Descriptions and Certificates of Coverage explicitly exclude coverage for weight loss surgery, many plans do cover surgery. In fact, some states require insurance companies to cover weight loss surgery, so even if your policy excludes it, if your state mandates coverage you may be in luck!

United Healthcare’s Pre-approval Criteria For Surgery

The following criteria must be met to receive coverage:

1. Class III Obesity (Body Mass Index greater than 40)
2. Class II Obesity (Body Mass Index greater than 35) with one or more of the following co-morbidities:
   1. Type 2 diabetes
   2. Cardiovascular disease (such as hypertension, stroke, angina)
   3. Severe sleep apnea or other life threatening cardiopulmonary conditions

For fully insured policies in Maryland:

1. A Body Mass Index above 40 without comorbidities, or
2. A Body Mass Index of 35 or greater with comorbidities including:
   1. Hypertension
   2. Sleep Apnea
   3. Diabetes
   4. Cardiopulmonary condition
   5. Any other life threatening medical condition that is weight-induced.
3. You must show proof that you’ve followed diets but were unsuccessful losing weight long term. These can include Jenny Craig, Weight Watchers, etc.
   • In the last two years you must have participated in:
     • One structured diet program for 6 consecutive months; or
     • Two structured diet programs for 3 consecutive months.
4. 18 years of age or older

Which Weight Loss Surgeries Are Covered by United Healthcare?

1. Gastric bypass
2. Lap Adjustable Gastric Bands (i.e. Lap Band or Realize Band Surgery)
3. Gastric Sleeve Procedure (also known as laparoscopic sleeve gastrectomy)
4. Vertical banded gastroplasty
5. Biliopancreatic bypass (Scopinaro procedure)
6. Duodenal switch

The following procedures are covered in adolescents:

1. Gastric bypass
2. Lap gastric bands
3. Gastric sleeve

Are lap gastric band fills covered?

Lap gastric band fills are covered for those patients that undergo Lap Band or Realize Band surgery.

What procedures are not covered?

1. Mini-gastric bypass
2. ROSE, StomaphyX, TOGA
3. Gastric electrical stimulation

Is a second weight loss surgery covered if lap band doesn’t work?

Yes. Assuming the same conditions to qualify for the original procedure are still met.

What if there is a problem? What if I don’t lose weight?

If you have a complication related to the surgery United Healthcare will cover any related procedures or hospital stay. If you do not lose weight and you still meet the original criteria for coverage a second procedure will be covered.

Does United Healthcare require a Center of Excellence?

As far as we can tell, no. But, by choosing an in-network surgeon, you will save on your out-of-pocket expenses.

United Healthcare’s Contact Information

Log into MyUHC to access your benefits and check your eligibility.  You can also call and ask if your policy includes coverage for CPT Code 43644.

43644 is the code for gastric bypass surgery. Even if you are not interested in gastric bypass surgery if gastric bypass surgery is covered then so will the other major bariatric surgery procedures.

United Healthcare’s Weight Loss Surgery Full Coverage Statement

United Healthcare’s full statement of coverage can be found here.