Does Humana Cover Bariatric Surgery?

Determining if Humana provides coverage for bariatric surgery involves understanding their specific policy guidelines and eligibility criteria.

This article outlines how to qualify for surgery, the types of procedures covered, and the financial responsibilities you may encounter with Humana. In particular, we will answer the question: does Humana cover bariatric surgery?

 

Key Takeaways

  • Humana offers coverage for bariatric surgery, including procedures such as gastric bypass and sleeve gastrectomy, but coverage is contingent on meeting specific eligibility criteria and is 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 might need their procedures performed by in-network providers or at Centers of Excellence.

 

  • Post-surgery assistance is available through Humana, including follow-up appointments and nutritional counseling. However, patients may face various out-of-pocket expenses such as deductibles, copayments, and coinsurance, with financial assistance programs available for qualifying individuals.

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Humana and Bariatric Surgery Coverage

Navigating the intricacies of insurance coverage can be a complex endeavor. You should be aware that Humana provides coverage for bariatric surgery. However, the specifics of this coverage hinge on the particulars of the individual policy and the fulfillment of certain criteria. Bear in mind that Humana requires patients to satisfy certain eligibility criteria for coverage.

Covering a range of procedures like gastric sleeve surgery, Humana’s coverage is contingent on the policyholder meeting specified coverage criteria. Health insurance providers, including Humana, can cover bariatric surgery, provided all necessary eligibility requirements are met.

 

Pre-Approval Requirements for Bariatric Surgery with Humana

Types of Weight Loss Surgeries Covered by Humana

Humana covers 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.

 

These surgeries involve diverse procedures and are all covered by Humana.

However, be aware that not all types of weight loss surgeries are covered. For instance, procedures like gastric plication are not covered. You 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 covered by Humana, there are some exceptions and limitations. The medical necessity documentation for bariatric surgery with Humana involves 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, are not covered by Humana insurance. Understanding these exclusions and limitations is critical before commencing your journey towards bariatric surgery.

Pre-Approval Requirements for Bariatric Surgery with Humana

Before Humana covers bariatric surgery, specific pre-approval requirements must be met. These requirements primarily revolve around documentation of medical necessity and a comprehensive psychological evaluation.

 

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A bariatric nurse plays a significant role in the approval process. They:

 

  • 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 ensures high-quality care for patients undergoing bariatric surgery or a bariatric procedure, with a focus on cover bariatric needs.

 

Medical Necessity Documentation

The road to bariatric surgery begins with the documentation of medical necessity. This involves providing evidence of obesity-related health issues and previous weight loss attempts. The criteria for obesity-related health issues 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 associated with obesity such as type 2 diabetes, sleep apnea, or hypertension.

 

To be eligible for weight loss surgery coverage through Humana, it is necessary to provide documentation demonstrating previous unsuccessful attempts at weight loss. Keeping detailed medical records is paramount to ensure a smooth navigation through the approval process.

 

Psychological Evaluation

Bariatric surgery is not just about physical transformation; it requires mental preparedness too. This is where the psychological evaluation comes in. It assesses the patient’s mental readiness for the substantial lifestyle changes that come with bariatric surgery.

The components of a psychological evaluation for bariatric surgery typically 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 is vital in identifying patients’ strengths and any psychiatric conditions that might impact the success of the surgery. This ensures that candidates are adequately prepared to manage the changes that come after the surgery.

In-Network Providers and Centers of Excellence

Choosing the right bariatric surgeon is a critical step in the journey towards a healthier life. Humana strongly recommends using an in-network bariatric surgeon for a variety of reasons. Selecting an in-network bariatric surgeon can result in reduced surgical costs.

 

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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 advises 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 is 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 can lead to cost savings and improved coverage.

 

Benefits of Choosing a Center of Excellence

A Center of Excellence in bariatric surgery is a designation awarded to a surgical center that meets specific criteria for safety and effectiveness. Humana gives this recognition to hospitals and surgeons who display an exceptional commitment and ability to consistently provide safe, high-quality, and successful bariatric surgery care.

In order to attain recognition as a Center of Excellence in bariatric surgery, a hospital or clinic is 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.

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Post-Surgery Support and Coverage

The journey doesn’t end with the surgery. Humana offers extensive post-surgery support and coverage. This includes follow-up appointments, monitoring, and nutritional counseling.

Humana offers coverage for bariatric procedures such as gastric bypass and laparoscopic banding, in addition to providing in-home care services to aid in the post-surgery recovery process. The post-surgery monitoring process with Humana involves their provider payment integrity postpayment review policy, which is designed to prevent fraud, waste, and abuse.

 

Follow-Up Appointments and Monitoring

Follow-up appointments after bariatric surgery are 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 involves 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.

 

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Post-operative monitoring typically includes regular biochemical monitoring and continuous monitoring of vital parameters to detect complications such as bleeding or anastomotic leakage.

 

Nutritional Counseling and Education

Nutritional counseling is a crucial component of the multidisciplinary team both pre and post bariatric surgery. It is instrumental in facilitating weight loss after the surgery and in preventing weight regain.

Humana provides a Bariatric Management Team that offers 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

Costs and Out-of-Pocket Expenses

While health insurance can cover a significant portion of the costs associated with bariatric surgery, there are still out-of-pocket expenses to consider. The typical cost range for bariatric surgery with Humana insurance can vary from $7,400 to $33,000 prior to insurance coverage.

Copayments for bariatric surgeries:

 

  • are predetermined fees
  • that a Humana policyholder is obligated to pay in accordance with their insurance agreement
  • the exact amount is 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 entails 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 can significantly influence the total cost of bariatric surgery with Humana by contributing to the out-of-pocket maximum. Once this threshold is met, the plan begins covering 100% of eligible services.

Bariatric surgeries covered by Humana have a minimum deductible of $1,500, with copayments typically at $700, and a coinsurance rate often set at $20. These figures denote the out-of-pocket expenses for the patient prior to the insurance covering the remaining costs.

The expenses for bariatric surgery differ across various insurance providers, typically ranging from $7,400 to $33,000 before insurance coverage. For a particular procedure such as the Gastric Sleeve Surgery, expenses generally average around $14,500.

 

Financial Assistance Programs

For patients who need help covering the costs of bariatric surgery, financial assistance programs may be available. Humana provides financial assistance for bariatric surgery through Medicare, the Extra Help program, and coverage under Humana Insurance.

 

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To qualify for Humana’s financial assistance for bariatric surgery, individuals must satisfy the criteria established by Humana, which entails 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 can confirm coverage with your Humana ID card or contact Humana directly. Upon contacting Humana, a Bariatric Management Team will provide guidance through the application process.

Navigating the Approval Process

Several steps are involved in navigating the approval process for bariatric surgery with Humana. Effective communication with your insurance specialist is key to understanding your coverage, requirements, and potential out-of-pocket costs.

One of the typical reasons for Humana denying coverage for bariatric surgery is 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 is 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 can 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’s 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 include:

 

  1. Ascertaining the inclusion of bariatric surgery in your policy
  2. Seeking details on the necessary CPT codes
  3. Verifying the coverage for medically essential weight loss surgery.

 

Appealing a Denial of Coverage

Being denied coverage for bariatric surgery can be a setback, but it’s not the end of the road. You can appeal the decision by providing additional documentation and working with your healthcare team.

 

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To initiate an appeal for the denial of coverage for bariatric surgery from Humana, follow these steps:

 

  1. Submit a written request through Availity Essentials or by mail within 60 days from the date of denial.
  2. As a member, you have the right to request an appeal for the coverage of bariatric surgery with Humana.
  3. The precise duration of the appeal process with Humana for bariatric surgery coverage is not disclosed. It is advisable for patients or their healthcare providers to directly communicate with Humana to obtain comprehensive information about the timeline of their appeal progress.

Summary

To conclude, understanding Humana’s coverage for bariatric surgery is critical for anyone considering this life-changing procedure. From meeting pre-approval criteria and choosing an in-network surgeon, through to navigating the approval process and understanding out-of-pocket expenses, every step is 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, 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 will help you qualify for the surgery.

 

Is bariatric surgery ever covered by insurance?

Yes, many insurance companies cover bariatric surgery if the qualification requirements are met.

 

Does Humana cover gastric sleeve surgery?

Yes, Humana covers gastric sleeve surgery if the patient meets the coverage criteria.

 

What are the exclusions or limitations in Humana’s coverage for bariatric surgery?

Humana’s coverage for bariatric surgery excludes specific procedures, such as Gastric Plication with the gastric band, Mini-gastric bypass, Stomaphyx, and other investigative procedures. Consider these limitations when considering bariatric surgery with Humana.

 

How do I find an in-network bariatric surgeon with Humana?

You can find an in-network bariatric surgeon with Humana by accessing your Humana account and using the ‘Find a doctor’ tool.

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Speak with a licensed insurance agent

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Russell Noga
( Medicare Expert )

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.