Cigna Insurance - WLS Benefits

WASaBubbleButt · June 7, 2009

Coverage Policy

Bariatric surgery is specifically excluded under many CIGNA 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 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:

? BMI (Body Mass Index) ≥ 40 for at least the previous 24 months.

? BMI (Body Mass Index) 35?39.9 for at least the previous 24 months with at least one clinically

significant comorbidity, including but not limited to, cardiovascular disease, Type 2 diabetes,

hypertension, coronary artery disease, or pulmonary hypertension

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Coverage Policy Number: 0051

? Active participation within the last two years in one physician-supervised 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:

? weight

? current dietary program

? physical activity (e.g., exercise program)

Programs such as Weight Watchers?, Jenny Craig? and Optifast? are acceptable alternatives if done in

conjunction with physician supervision and detailed documentation of participation is available for

review. For individuals with long-standing, morbid obesity, participation in a program within the last five

years is sufficient if reasonable attendance in the weight-management program over an extended period

of time of at least six months can be demonstrated. However, physician-supervised programs consisting

exclusively of pharmacological management are not sufficient to meet this requirement.

? Evaluation by a multidisciplinary team within the previous 12 months which includes the following:

? an evaluation by a surgeon qualified to do bariatric surgery recommending surgical treatment

? a separate medical evaluation recommending bariatric surgery

? clearance for surgery by a mental health provider

? a nutritional evaluation by a physician or registered dietician

Bariatric Surgery Procedures:

When the specific medical necessity criteria noted above for bariatric surgery have been met, CIGNA

covers ANY of the following open or laparoscopic bariatric surgery procedures:

? vertical banded gastroplasty

? Roux-en-Y gastric bypass

? laparoscopic adjustable silicone gastric banding (e.g., LAP-BAND?, REALIZE?)

? biliopancreatic diversion with duodenal switch (BPD/DS) for individuals with a BMI (Body Mass Index) > 50

CIGNA covers adjustment of a silicone gastric banding as medically necessary to control the rate of

weight loss and/or treat symptoms secondary to gastric restriction following a medically necessary

adjustable silicone gastric banding procedure.

CIGNA does not cover the following bariatric surgery procedures, because they are considered

experimental, investigational or unproven (this list may not be all-inclusive):

? Fobi-Pouch (limiting proximal gastric pouch)

? gastroplasty (stomach stapling)

? intestinal bypass (jejunoileal bypass)

? intragastric balloon

? loop gastric bypass

? mini-gastric bypass

? sleeve gastrectomy (SG)

? Natural Orifice Transluminal Endoscopic Surgery? (NOTES?) (e.g., StomaphyX?)

Reoperation and Repeat Bariatric Surgery:

CIGNA covers surgical reversal (i.e., takedown) of bariatric surgery as medically necessary when the

individual develops complications from the original surgery such as stricture or obstruction.

CIGNA covers revision of a previous bariatric surgical procedure or conversion to another medically

necessary procedure due to inadequate weight loss as medically necessary when ALL of the following

are met:

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Coverage Policy Number: 0051

? Coverage for bariatric surgery is available under the participant's current health benefit plan.

? There is evidence of full compliance with the previously prescribed postoperative dietary and exercise

program.

? Due to a technical failure of the original bariatric surgical procedure (e.g., pouch dilatation) documented

on either upper gastrointestinal (UGI) series or esophagogastroduodenoscopy (EGD), the patient has

failed to achieve adequate weight loss, which is defined as failure to lose at least 50% of excess body

weight or failure to achieve body weight to within 30% of ideal body weight at least two years following

the original surgery.

? The requested procedure is a regularly covered bariatric surgery (see above for specific procedures).

NOTE: Inadequate weight loss due to individual noncompliance with postoperative nutrition and

exercise recommendations is not a medically necessary indication for revision or

conversion surgery and is not covered by CIGNA .

Cholecystectomy and Liver Biopsy:

CIGNA covers cholecystectomy performed at the time of bariatric surgery as medically necessary when

the bariatric surgery is determined to be medically necessary and EITHER of the following criteria is

met:

? Preoperative or intraoperative evidence of gallstones or biliary sludge.

? Recent history of cholecystitis.

CIGNA does not cover either prophylactic cholecystectomy (incidental removal of a nondiseased

gallbladder) or routine liver biopsy at the time of bariatric surgery, because each is considered

experimental, investigational or unproven.

carolnphx · June 7, 2009

Wow, I knew there was a reason I went private pay. I knew the rules were more than I wanted/could deal with but Wow this is mind boggling to see just a partial listing.

I take my hat off to all of you that have gone through the hoops of your ins to get WLS.

laylasmojo · July 26, 2010

hello just an update for those out there looking... I am not sure of Cigna overall but Cigna harrahs does cover VSG now(Yes there are hoops but they do cover) so if you are any branch of Cigna it wont hurt to look into it.