Disclaimer: This article provides general information about IEHP’s policy for weight loss surgery coverage. It should not be considered medical advice or a definitive source on all requirements or exclusions. Consult directly with your insurance plan and care providers regarding your benefits and obligations.
Weight loss surgery, also known as bariatric surgery, refers to a variety of procedures performed on people struggling with severe obesity. These surgeries promote significant weight loss by restricting food intake, decreasing absorption of nutrients, or both. Common types of weight loss surgeries include gastric bypass, sleeve gastrectomy, adjustable gastric band, and biliopancreatic diversion with duodenal switch.
For many people struggling with their weight, bariatric surgery can be an effective solution when diet and exercise alone have not worked. However, weight loss surgery is a major procedure that comes with risks and life-long impacts. As such, health insurance coverage for these expensive surgeries can be limited or dependent on meeting strict criteria.
So does IEHP (Inland Empire Health Plan) cover weight loss surgery procedures for its members? **The short answer is yes, IEHP does cover bariatric surgery when specific conditions are met.** Keep reading to learn more about IEHP’s exact requirements and processes for getting approval for weight loss operations.
IEHP’s Bariatric Surgery Coverage
As stated in IEHP’s bariatric surgery policy, the health plan does cover medically necessary bariatric procedures for members who meet certain qualifications.
However, IEHP has strict criteria that must be satisfied before authorization can be obtained, including:
- You must complete 6 months of focused effort within the last 2 years of physician-supervised weight loss treatment that includes monthly doctor visits as well as dietary, nutritional, and exercise counseling
- Your body mass index (BMI) must be ≥40 OR between 35 and 39.9 along with at least 1 co-morbid condition like heart disease or diabetes that is expected to improve with weight loss
- You must undergo a full medical and psychological evaluation to determine surgery readiness
Assuming all prerequisites are fulfilled, the following bariatric procedures are covered by IEHP:
- Roux-en-Y gastric bypass
- Sleeve gastrectomy
- Adjustable gastric banding
- Biliopancreatic diversion with duodenal switch (for people with super obesity)
Getting Authorization from IEHP for Bariatric Surgery
If you meet the basic criteria above, obtaining actual approval for weight loss surgery is an involved process with IEHP. Here are the general steps:
- Consult with your primary care provider about your interest in bariatric surgery and ask for a referral to an IEHP contracting bariatric surgeon.
- Attend your consultation with the bariatric surgeon and additional specialists like a dietitian, psychologist, and high-risk interventionist. They will evaluate if you meet the full criteria.
- Undergo all required medical and psychological testing to establish that surgery is appropriate. This includes things like nutritional assessments, upper GI radiography or endoscopy, cardiac clearance tests, sleep studies for sleep apnea, etc.
- Have your bariatric surgeon submit the request for surgery authorization to IEHP along with all test results showing that prerequisites are met.
- IEHP’s utilization management team reviews the request against policy criteria. They either approve it, pend it for more information, or issue an adverse determination if criteria are not met.
- If approved, you undergo a 1-2 week pre-op diet before having your bariatric surgery performed.
The above outlines the general workflow but your individual surgeon’s office will guide you through specifics. Just know that IEHP does cover bariatric procedures but approval involves many stringent steps.
Covered Expenses and Limitations
If your weight loss surgery is approved by IEHP, the health plan will cover hospital facility charges, anesthesiology, labs, physician services, and 90 days of post-op care as long as everything occurs at an in-network facility with contracted providers.
However, certain limitations exist in IEHP’s bariatric coverage, including:
- Only 1 obesity surgery procedure is allowed per lifetime
- Revisions, reversals, or conversions of prior bariatric surgeries are not covered
- Cosmetic body contouring procedures after major weight loss are excluded
- Travel expenses are not reimbursed
So review the details carefully with your providers to understand exactly what services will and will not be paid for by IEHP after your surgery. Get all financial obligations clarified upfront.
Is Preparation Help Available?
Embarking on major bariatric surgery involves big lifestyle changes before and especially after the operation. Services to equip members for success can include medical nutritional therapy, behavioral health integration programs, support groups, and specialty care management with an IEHP Nurse Case Manager.
Discuss all preparation and long-term support options with your bariatric surgery team and primary care doctor so you fully understand what resources are accessible with your IEHP insurance coverage around the life-altering decision to undergo weight loss surgery.
Frequently Asked Questions IEHP Weight Loss Surgery
Does IEHP have in-network bariatric surgeons?
Yes, IEHP contracts with certain designated bariatric surgeons and facilities to perform covered weight loss procedures for members. Consult IEHP’s provider directory or ask your PCP for help finding options.
If I already had a surgery consultation, can IEHP retroactively approve and cover it?
Unfortunately not. IEHP requires their prior authorization process to be followed first. They will not backdate approvals or pay for services already rendered without approval.
Can I choose any bariatric surgeon if IEHP is covering it?
No, you must choose an in-network provider with IEHP for the health plan to cover any bariatric surgery fees. Using an out-of-network surgeon would require you to pay all charges yourself.
Does IEHP impose any age requirements for bariatric surgery approval?
Yes. IEHP generally does not approve weight loss operations for those under 18 years old. Requirements get stricter for adolescents under certain ages.
Is there a maximum BMI cutoff where IEHP won’t cover surgery?
IEHP has not set an upper limit BMI disqualifier. As long as all policy criteria are met, approval can be obtained even with very high BMIs in severe obesity.
Conclusion
Navigating health insurance benefits for major procedures like weight loss surgery can be confusing. But in summary – yes IEHP does cover bariatric operations including gastric bypass, gastric sleeve, and more when strict conditions are met.
Working closely with your PCP, IEHP team, and chosen bariatric surgery program will help ensure you fully understand the approval process and coverage before taking this big step. Weight loss surgery can serve as a lifesaving tool for those struggling with severe obesity and related illnesses, but the journey requires great preparation and support. Review all the specifics on IEHP’s bariatric surgery policy with your care team so you know exactly what to anticipate should you be interested in obtaining authorization for a weight loss operation in the future.
Humayun Islam is a passionate medical writer and health enthusiast. His goal is to take complex medical information and present it in a way that is accessible and engaging to a broad audience.
When he is not writing, Humayun enjoys spending time with his family, being outdoors, and reading nonfiction books. He is constantly learning about new medical advancements and public health initiatives so he can provide readers with the most up-to-date information. Humayun joined the Quick Medico team in 2023 and is excited to share his medical knowledge and writing expertise. He hopes his articles will educate readers on a wide range of health topics and empower them to make informed decisions about their well-being.