What you need to know about bariatric surgery
Each weight loss journey is unique and requires different tools depending on your individual goals and needs. Bariatric surgery may be beneficial for some individuals. Optum Bariatric Resource Services (BRS) can help you explore this option in collaboration with your Medical Weight Loss team.
BRS provides support through bariatric nurse case managers who will assess your needs over the phone to determine if surgery is a good fit for you. If so, they will recommend a BRS Network Center of Excellence (COE) and surgeon. You will work with the surgical team to prepare for surgery while continuing to work with your Medical Weight Loss team for optimal results post-surgery.
Eligibility for surgery
Weight-loss surgery services are part an eligible medical plan and are offered to enrolled employees and their spouse or domestic partner.
Eligible UnitedHealth Group plans include HSA Plans (Low Premium Plan and Low Deductible Plan), Accountable Care Plan, Charter Copay Plan, M Health Fairview Primary Care Plan, WellMed 1st Tier Plan, Hawaii* PPO Plan and Surest Flex Copay Plan.
Eligible OptumCare plans include HSA Plan, Accountable Care Plan, Doctors Plan, OptumCare NE Plan, OptumCare EPO Plan and Surest Flex Copay Plan.
Eligibile Optum Select plans include Optum Select HSA Plan, Optum Select Copay Plan, and Optum Select Surest Plan.
In addition, the following criteria must be met for surgery to be covered through your medical plan:
- You are age 18 or over (dependent children are not eligible for coverage).
- You have a minimum Body Mass Index (BMI) of 40 kg/m2 or BMI ≥ 35 kg/m2 with at least 1 weight-related chronic condition (documented at the onset of a physician-monitored nutritional program such as MWL).
- You must participate in a physician-monitored nutritional program (includes MWL) for a minimum of 3 months.
- You must enroll in the Optum Bariatric Resource Services (BRS) program and meet all behavioral and clinical criteria to ensure best outcomes.
- You must use a BRS Network Center Of Excellence provider and facility.
- One surgery per lifetime while covered under the policy, unless complications related to the surgery arise (weight regain is not a definition of surgical complications).**
- Coverage is limited to only gastric bypass and sleeve gastrectomy (gastric band and switch are excluded).
*Hawaii plan members should call Health Care Advisor or review their plan materials to understand their coverage for bariatric surgery.
**Excess skin removal post-bariatric surgery is not covered, unless medically necessary.
BRS program details
If you are interested in surgery, you can be referred to BRS by your Medical Weight Loss care team. The referral typically occurs in month two or three of your program. Three-month participation in Medical Weight Loss and BRS enrollment is a requirement for bariatric surgery coverage.
While in the BRS program, you will be assigned a nurse case manager. The BRS nurse or engagement specialist will recommend a BRS Network Center of Excellence (COE) and an associated surgeon. The BRS process consists of:
- Initial call
- Follow-up call
- Two post-op calls at one week and one month post-surgery
The BRS RN will discuss your surgical requirements and prior authorization needs during the initial call. Plus, they will provide ongoing support and guidance throughout the approval process. Once pre-surgery requirements are met, the surgeon will submit a prior authorization for surgery to the BRS team. When approved, surgery can be performed at the COE.
The BRS program includes support for reviewing barriers to care, discussing health aspects, medication reconciliation, post-surgery plans, lifestyle modifications, return to work plans, goal setting and more.
To learn more about bariatric surgery, visit the bariatric resources library or call Bariatric Resource Services (BRS) at 1-888-936-7246.
After surgery
Weight loss is a lifelong journey and that continues even after surgery. Your surgical and Medical Weight Loss care team will be here to give you the ongoing support you need to maintain your weight loss and enjoy continued health benefits.
For the first six to twelve months after surgery, you will work closely with your surgical team to help you adjust to your smaller stomach and to the changes that occur after surgery.
Your Medical Weight Loss care team knows that you will have many appointments after your surgery. After six months, someone from your team will reach out to you to provide you with additional support. We are here to help make sure that you are getting proper nutrition and that you are in the best physical and mental shape possible.
Resources
Like any medical procedure, the decision to schedule bariatric weight-loss surgery should not be made lightly. Know the benefits available to you, such as travel and lodging assistance, and review the library of resources* available to determine whether the procedure is the right fit for you.
Travel and lodging assistance
Travel and Lodging Assistance is only available for the employee or their eligible family member if they meet the qualifications for the benefit, including:
- Enrolling in the BRS program,
- Receiving care at an eligible BRS Network Center of Excellence (COE), and
- Having a distance from your home address to the facility that is greater than 50 miles
All eligible expenses are reimbursed after the expense forms have been completed and submitted with the appropriate, legible receipts. Call Health Care Advisor at 1-800-357-1371 if you are a UnitedHealthcare member or Surest member services if you are a Surest member to learn more about how to submit your receipts and documentation.
The lifetime maximum that can be reimbursed under Travel and Lodging Assistance is up to $2,000.
Reimbursement is not provided until after service (appointment or surgery) has been performed.
For eligible expense information, call Health Care Advisor at 1-800-357-1371 or the Travel and Lodging Office at 1-800-842-0843 and leave a message. Calls will be returned within 48 business hours.
*The library of resources includes more surgeries than are covered on your medical plan. The bariatric surgery benefit covers the Roux-en-Y gastric bypass or the vertical sleeve gastrectomy procedures.
