The Plan covers surgical treatment of obesity provided by or under the direction of a Physician provided all of the following is true:
- You have a minimum Body Mass Index (BMI) of 40 irrespective of comorbities, or greater than 35 with at least one comorbity directly related to, or exacerbated by morbid obesity:
- Type 2 diabetes or pre-diabetes
- Cardiovascular disease (e.g., stroke, myocardial infarction, poorly controlled hypertension (systolic blood pressure greater than 140 mm Hg or diastolic blood pressure 90 mm Hg or greater, despite pharmacotherapy)
- History of coronary artery disease with a surgical intervention such as cardiopulmonary bypass or percutaneous transluminal coronary angioplasty
- Cardiopulmonary problems (e.g., documented obstructive sleep apnea (OSA) confirmed on polysomnography with an AHI or RDI of >= 30 (as defined by AASM Task Force. Sleep.1999;22:667-89)
- History of cardiomyopathy
- High Cholesterol or Hyperlipidemia
- Polycystic Ovarian Syndrome (PCOS)
- You are over the age of 18 or, for adolescents, have achieved greater than 95% of estimated adult height AND a minimum Tanner Stage of 4.
- You have a 3-month physician or other health care provider supervised diet documented within the last 2 years.
- You have completed a multi-disciplinary surgical preparatory regimen, which includes a psychological evaluation.
- You are having your first bariatric surgery under your plan, unless there were complications with your first procedure.
- You have a 3-month physician supervised diet documented within the last 2 years.
Benefits for obesity surgery services are covered only if they meet the definition of a covered health service (see "Medical plan definitions") and are not considered experimental, investigational or unproven. Benefits are limited to one surgery per lifetime unless there are complications to the covered surgery.
For out-of-network benefits you must obtain prior authorization from UnitedHealthcare as soon as the possibility of obesity surgery arises.
If you fail to obtain prior authorization from UnitedHealthcare as required, benefits will be subject to a $400 penalty.