Does Humana Cover Bariatric Surgery?
Determining if Humana provides coverage for bariatric surgery will likely involve understanding their specific policy guidelines and eligibility criteria.
This article outlines how to qualify for surgery, the types of procedures covered, and the potential financial responsibilities you may encounter with Humana.
Key Takeaways
- Humana will likely offer coverage for bariatric surgery, which might include procedures such as gastric bypass and sleeve gastrectomy, but coverage may also be contingent on meeting specific eligibility criteria and will likely be subject to plan-specific exclusions and limitations.
- To be approved for bariatric surgery coverage, Humana policyholders must provide medical necessity documentation, undergo a comprehensive psychological evaluation, and have their procedures performed by in-network providers or at Centers of Excellence.
- Post-surgery assistance could be available through Humana, which may include follow-up appointments and nutritional counseling. However, patients may face various out-of-pocket expenses such as deductibles, copayments, and coinsurance, with some financial assistance programs that may be available for qualifying individuals.
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Humana and Bariatric Surgery Coverage
Navigating the intricacies of insurance coverage could be a complex endeavor. You should be aware that Humana will likely provide coverage for bariatric surgery. However, the specifics of this coverage may hinge on the particulars of the individual policy and the fulfillment of certain criteria. Bear in mind that Humana may also require patients to satisfy certain eligibility criteria for coverage.
By potentially covering a range of procedures like gastric sleeve surgery, Humana’s coverage could be contingent on the policyholder meeting specified coverage criteria. Health insurance providers, including Humana, may cover bariatric surgery, provided all necessary eligibility requirements have been met.
Types of Weight Loss Surgeries Covered by Humana
Humana may also cover a range of weight loss surgeries, including:
- Gastric bypass: This surgery reroutes the digestive system.
- Lap band or realize band surgery: This procedure involves adjustable gastric banding.
- Sleeve gastrectomy: This surgery reduces the size of the stomach.
- Duodenal switch surgery: This is another option for weight loss surgery.
Some of these surgeries may also involve diverse procedures and will likely be covered by Humana.
However, be aware that not all types of weight loss surgeries are covered. For instance, procedures like gastric placation might not be covered. You will likely need to get acquainted with the specific surgeries and variations included in the coverage, as not all insurance plans cover weight loss surgery.
Exclusions and Limitations
Despite the wide range of bariatric surgeries that could be covered by Humana, there may be some exceptions and possible limitations. The medical necessity documentation for bariatric surgery with Humana will likely involve providing evidence of obesity-related health issues, such as severe sleep apnea, and previous weight loss attempts.
Some specific bariatric surgeries, including Gastric Plication (with the gastric band), Mini-gastric bypass, and Stomaphyx, among others, also might not be covered by Humana insurance. Understanding these possible exclusions and limitations could be critical before commencing your journey toward bariatric surgery.
Pre-Approval Requirements for Bariatric Surgery with Humana
Before Humana covers bariatric surgery, certain pre-approval requirements must be met. These requirements will likely revolve around documentation of medical necessity and a comprehensive psychological evaluation.
A bariatric nurse could play a significant role in the approval process. They will likely:
- Assess whether the patient meets the necessary medical criteria
- Collaborate with the bariatric medical director as needed
- Verify the surgeon’s credentials
- Check if the bariatric hospital has been certified as a Center of Excellence by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)
This could ensure high-quality care for patients undergoing bariatric surgery or a bariatric procedure, with a focus on covering bariatric needs.
Medical Necessity Documentation
The road to bariatric surgery begins with the documentation of medical necessity. This might involve providing evidence of obesity-related health issues and previous weight loss attempts. The criteria for obesity-related health issues may include:
- Being 100 pounds or more above ideal weight
- Having a Body Mass Index (BMI) of 40 or greater
- Having a BMI of 35 or more and suffering from medical problems that have been associated with obesity such as type 2 diabetes, sleep apnea, or hypertension.
To be eligible for weight loss surgery coverage through Humana, it might be necessary to provide documentation demonstrating previous unsuccessful attempts at weight loss. Keeping detailed medical records could be paramount to ensure a smooth navigation through the approval process.
Psychological Evaluation
Bariatric surgery might not just be about physical transformation; it may require mental preparedness too. This is where the psychological evaluation comes in. It may assess the patient’s mental readiness for the substantial lifestyle changes that come with bariatric surgery.
The components of a psychological evaluation for bariatric surgery may include assessing the patient’s:
- Reasons for seeking surgery
- Weight and diet history
- Current eating behaviors
- Understanding of the surgery and lifestyle changes
- Social supports
- Any present or past psychiatric symptoms
The psychological evaluation could be vital in identifying patients’ strengths and any psychiatric conditions that might impact the success of the surgery. This could potentially ensure that candidates may be adequately prepared to manage the changes that come after the surgery.
In-Network Providers and Centers of Excellence
Choosing the right bariatric surgeon could be a critical step in the journey toward a healthier life. Humana will likely recommend using an in-network bariatric surgeon for several reasons. Selecting an in-network bariatric surgeon could potentially result in reduced surgical costs.
To locate an in-network bariatric surgeon with Humana, you can access your Humana account and utilize the ‘Find a Doctor’ tool to search for providers within your network. Moreover, Humana may also advise that the surgery should be conducted at an accredited Center of Excellence when utilizing an in-network surgeon.
Finding an In-Network Bariatric Surgeon
Finding an in-network bariatric surgeon may be easier than you might think. With Humana’s online provider directory, individuals can log in to Humana’s website and utilize their provider search tool. This tool facilitates the identification of bariatric surgeons who are affiliated with Humana’s network.
For any further inquiries, you can always reach out to Humana’s customer service number at 800-457-4708.
They can provide you with the contact information for in-network bariatric surgeons. When choosing an in-network bariatric surgeon with Humana, it’s important to ensure the surgeon is part of Humana’s network as this could potentially lead to cost savings and improved coverage.
Possible Benefits of Choosing a Center of Excellence
A Center of Excellence in bariatric surgery will likely have a designation awarded to a surgical center that meets specific criteria for safety and effectiveness. Humana might give this recognition to hospitals and surgeons who display an exceptional commitment and ability to consistently provide safe, high-quality, and successful bariatric surgery care.
To attain recognition as a Center of Excellence in bariatric surgery, a hospital or clinic may be required to:
- Conduct a minimum of 125 bariatric surgeries annually
- Employ board-certified surgeons with substantial expertise
- Undergo a thorough reporting and inspection procedure administered by the American Society for Metabolic and Bariatric Surgery (ASMBS)
Patients who seek treatment at a Center of Excellence for bariatric surgery may experience improved patient outcomes.
Post-Surgery Support and Coverage
The journey doesn’t end with the surgery. Humana might offer extensive post-surgery support and coverage. This could include follow-up appointments, monitoring, and nutritional counseling.
Humana may also offer coverage for bariatric procedures such as gastric bypass and laparoscopic banding, in addition to potentially providing in-home care services that could aid in the post-surgery recovery process. The post-surgery monitoring process with Humana will likely involve their provider payment integrity post payment review policy, which has been designed to prevent fraud, waste, and abuse.
Follow-Up Appointments and Monitoring
Follow-up appointments after bariatric surgery may be essential for timely identification of any issues, regular blood work and diagnostic testing, preserving good health, achieving weight loss objectives, and adhering to weight management plans.
The standard protocol for post-operative appointments following bariatric surgery will likely involve scheduled visits at one, three, six, and 12 months after the procedure, with an initial follow-up video visit arranged for two to three weeks post-surgery.
Post-operative monitoring may also include regular biochemical monitoring and continuous monitoring of vital parameters to detect complications such as bleeding or anastomotic leakage.
Nutritional Counseling and Education
Nutritional counseling could be a crucial component of the multidisciplinary team both pre and post bariatric surgery. This could be instrumental in facilitating weight loss after the surgery and in preventing weight regain.
Humana may also provide a Bariatric Management Team that could offer guidance and support to patients as they navigate through the weight loss surgery process. According to ASMBS guidelines, post-bariatric surgery patients should receive nutritional counseling at the following intervals:
- Month 1
- Month 3
- Month 6
- Month 9
- Month 12
Potential Costs and Out-of-Pocket Expenses
While health insurance could cover a significant portion of the costs that may be associated with bariatric surgery, there will likely still be out-of-pocket expenses to consider.
Copayments for bariatric surgeries are predetermined fees that a Humana policyholder may be obligated to pay by their insurance agreement and the exact amount will likely be contingent upon the specific plan.
Coinsurance refers to the percentage of expenses for a covered healthcare service that the individual is responsible for after meeting the deductible. With Humana, this might entail the individual paying a portion of the total cost of bariatric surgery once the deductible requirement has been fulfilled.
Deductibles, Copayments, and Coinsurance
Deductibles, copayments, and coinsurance could also significantly influence the total cost of bariatric surgery with Humana by potentially contributing to the out-of-pocket maximum. Once this threshold is met, the plan may begin to cover up to 100% of eligible services.
Financial Assistance Programs
For patients who may need help covering the costs of bariatric surgery, financial assistance programs may be available. Humana may also provide financial assistance for bariatric surgery through Medicare, the Extra Help program, and coverage under Humana Insurance.
To qualify for Humana’s financial assistance for bariatric surgery, individuals must satisfy the criteria established by Humana, which could entail having a body mass index (BMI) exceeding 35 and presenting with at least one other comorbidity.
To apply for Humana’s financial assistance program for bariatric surgery, you should confirm coverage with your Humana ID card or contact Humana directly. Upon contacting Humana, a Bariatric Management Team will guide you through the application process.
Navigating the Approval Process
Several steps will likely be involved in navigating the approval process for bariatric surgery with Humana. Effective communication with your insurance specialist may be key to understanding your coverage, requirements, and potential out-of-pocket costs.
One possible reason for Humana denying coverage for bariatric surgery may be the absence of adequate medical records to justify the necessity of the procedure. To tackle this issue, it is important to ensure that all essential medical documentation has been submitted along with the claim and to utilize Humana’s Claim Status tool for any required reconsideration or appeals.
Communicating with Your Insurance Specialist
Communicating effectively with your insurance specialist could be a game-changer. The recommended communication practices involve:
- Using clear and simple language
- Adopting an appropriate tone of communication
- Simplifying information for consumers
- Establishing a dependable customer support system
- Creating a centralized location for accessing information and forms
- Being proactive in anticipating the needs of clients
When interacting with your insurance specialist, it may also be advisable to:
- Be prepared
- Share relevant information
- Ask pertinent questions
- Request documentation in writing
- Ensure to follow up on any outstanding matters.
Inquiries to pose to your insurance specialist concerning bariatric surgery coverage might include:
- Ascertaining the inclusion of bariatric surgery in your policy
- Seeking details on the necessary CPT codes
- Verifying the coverage for medically essential weight loss surgery.
Appealing a Denial of Coverage
Being denied coverage for bariatric surgery could be a setback, but it’s not the end of the road. You may appeal the decision by providing additional documentation and working with your healthcare team.
To initiate an appeal for the denial of coverage for bariatric surgery from Humana, follow these steps:
- Submit a written request through Availity Essentials or by mail within 60 days from the date of denial.
- As a member, you have the right to request an appeal for the coverage of bariatric surgery with Humana.
- The precise duration of the appeal process with Humana for bariatric surgery coverage has not been disclosed yet. However, it may be advisable for patients or their healthcare providers to directly communicate with Humana to obtain comprehensive information about the approximate timeline of their appeal progress.
Summary
Understanding Humana’s coverage for bariatric surgery could be critical for anyone considering this life-changing procedure. From meeting pre-approval criteria and choosing an in-network surgeon, to navigating the approval process and understanding the potential out-of-pocket expenses, every step may be crucial.
Remember, the journey doesn’t end with the surgery. Post-surgery support and nutritional counseling are essential for long-term success.
Frequently Asked Questions
→ What do I say to get approved for bariatric surgery?
To increase your chances of getting approved for bariatric surgery, you should focus on meeting the eligibility requirements such as having a BMI of 35 or higher or having a BMI between 30 and 35 with an obesity-related condition. This could help you qualify for the surgery.
→ Is bariatric surgery ever covered by insurance?
Yes, many insurance companies may cover bariatric surgery if the qualification requirements are met.
→ Does Humana cover gastric sleeve surgery?
Yes, Humana might cover gastric sleeve surgery if the patient meets the coverage criteria.
→ What are the potential exclusions or limitations in Humana’s coverage for bariatric surgery?
Humana’s coverage for bariatric surgery may exclude specific procedures, such as Gastric Plication with the gastric band, Mini-gastric bypass, Stomaphyx, and other investigative procedures. Consider these potential limitations when considering bariatric surgery with Humana.
→ How do I find an in-network bariatric surgeon with Humana?
You could find an in-network bariatric surgeon with Humana by accessing your Humana account and using the ‘Find a doctor’ tool.
ZRN Health & Financial Services, LLC, a Texas limited liability company
Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.