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For more information about qualifying for bariatric surgery, see "Related Items" below.
NOTE: "The plans" refers to UMP Classic and UMP CDHP.
Which surgeries are covered?
The plans cover only certain surgeries and only in very specific circumstances when approved by a plan medical director:
- For members ages 21-64, the plans cover laparoscopic adjustable gastric banding, Roux-en-Y, or sleeve gastrectomy surgery as stated in "Bariatric Surgery Criteria for Coverage."
- For members ages 18-20, the plans cover only the laparoscopic adjustable gastric banding surgery as defined in Regence BlueShield medical policy and outlined in the Health Technology Assessment decision.
Members ages 65 or older should check with Medicare for coverage. If Medicare approves bariatric surgery, the plans will pay second after Medicare.
See here if you are age 64 and will be eligible for Medicare soon.
Who will be considered for coverage of bariatric surgery?
Because bariatric surgery requires significant, permanent lifestyle changes, members must first meet strict criteria to be considered. See "Criteria for Coverage" for complete information.
Bariatric (obesity) surgery is covered only in very specific clinical circumstances, including comorbid conditions, and must be preauthorized by the plan. The plan will cover the surgery only
if the patient meets all program requirements, including those for before and after surgery.
If you meet the initial criteria for coverage, you will be referred to a Regence case manager, who will refer you to a bariatric surgery center. You will be required to meet the plan's criteria for weight loss under a structured weight-loss program before being approved for bariatric surgery. Your assigned bariatric surgery center will determine how much weight you must lose and will work with your Regence case manager.
The final decision to approve surgery is made by a plan medical director after you meet all presurgical requirements. Once approved, you must use providers and facilities designated as Centers of Excellence by UMP.
*The plan does not cover costs associated with weight-loss programs and members are responsible for the full program cost. This amount does not apply to your deductible or out-of-pocket maximum.