Hi, I have Cigna. Here is what mine says:
Coverage Position
Bariatric surgery is explicitly excluded under many CIGNA HealthCare benefit plans and may be
governed by state and/or federal mandates. Please refer to the applicable benefit plan document
to determine benefit availability and the terms and conditions of coverage.
Unless excluded from the benefit plan, this service is covered when the following medical
necessity criteria are met.
CIGNA HealthCare covers bariatric surgery using a covered procedure outlined below as
medically necessary when ALL of the following criteria are met:
•
The individual is ≥ 18 years of age or has reached full expected skeletal growth AND has
evidence of one of the following:
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BMI (Body Mass Index) ≥ 40 for at least the previous 12 months.
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BMI (Body Mass Index) 35–39.9 for at least the previous 12 months with at least one
clinically significant comorbidity, such as a serious cardiopulmonary problem, Type 2
diabetes, hypertension, coronary artery disease, or pulmonary hypertension that has failed to
respond adequately to appropriate medical management.
•
Active participation within the last two years in one physician-directed weight-management
program for a minimum of six months without significant gaps. The weight-management program
must include monthly documentation of ALL of the following components: Ok, now, I read this and thought I wouldn't be covered. BUT, I looked on the website for the weight loss center (I live in North Carolina so Duke will do the surgery). It specifically states the codes to ask your insurance company about. So, I called Cigna, armed with this information. They took my member number and checked to see if indeed I am covered. Also, I called once before the information session at Duke. Then, I called again after that session (just to make sure). They even gave me the complete thread, using my membership information, to find this on the website. Insurance companies are not easy to deal with in general. But I have to say, I have been encouraged to this point with the answers I have been getting. I encourage you to call them and ask them directly if the code is covered. Here is the specific question list I used to ask Cigna about coverage: 1. Is Morbid Obesity a covered benefit in your policy or is it an EXCLUSION? Give them the diagnostic ICD9 Code of 278.01. If morbid obesity is a covered benefit, check that the operative procedure you are considering is also covered. For the Roux-en-Y procedure give them the CPT Code of 43846 or 43644 and for the Lap Band procedure give them the CPT Code of: 43643 (Note that many insurance companies do not yet approve the Lap Band Procedure so check carefully with your company if this is your selection). Finally ask if your hospital and the doctors you want to use are covered by Cigna.
And lastly, I think that the code for Lap Band is now 43644, but not certain. What I would do is give them the 43643 number and then ask if there is any code covered for it and take that info down. Then call the folks doing the surgery and ask "Is this the code that will cover my procedure."
I hope this helps!
Ks
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