Does Cigna Cover Bariatric Surgery in Arizona?

Cigna is one of the largest health insurance providers in the United States, and, like most insurers, does provide coverage for bariatric surgery in Arizona when specific medical criteria are met. However, the caveat is that individual plan benefits and exclusions take precedence over the general policy guidelines.

Cigna’s coverage for bariatric surgery or revision procedures can vary by plan type and employer group. The first step is to review your individual plan documents, such as your Summary Plan Description (SPD) or Certificate of Coverage, to understand your specific benefits, exclusions, and preauthorization requirements.

Please contact Cigna directly or our office to confirm whether your plan includes bariatric surgery benefits and what specific requirements apply, to avoid financial surprises.

General Requirements for Coverage

While each plan may differ, Cigna generally considers bariatric surgery for adults (age 18 and older) medically necessary when all of the following criteria are met.

BMI and Comorbidity Requirements

BMI greater than or equal to 35 (or ≥ 27.5 for individuals of Asian ethnicity with provider attestation)
BMI between 30-34.9 (or 25-27.4 for individuals of Asian ethnicity with provider attestation) with at least one significant obesity-related comorbidity, such as:
- Type 2 diabetes
- Poorly controlled hypertension
- Hyperlipidemia
- Coronary artery disease
- Obstructive sleep apnea
- Pulmonary hypertension
- Fatty liver disease (MASLD/MASH)
- Gastroesophageal reflux disease (GERD)
- Degenerative joint disease in a weight-bearing joint

Pre-Surgical Requirements

Within the 12 months prior to surgery, patients are also required to complete a thorough evaluation that includes:

A detailed description of the proposed bariatric procedure
Documentation of unsuccessful weight loss attempts with medical management
Mental health clearance from a licensed provider
A nutritional evaluation by a physician, PA, NP, or registered dietitian

Covered Bariatric Procedures

When all of the above medical necessity criteria are met, Cigna may cover the following types of procedures:

Sleeve gastrectomy
Roux-en-Y gastric bypass (standard or long-limb)
Biliopancreatic diversion (with or without duodenal switch)
Single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S)
Adjustable gastric banding (Lap-Band® or Realize™)
Vertical banded gastroplasty

Note: Adjustment of a silicone gastric band may be covered when medically necessary to control weight loss or manage symptoms. Procedures considered experimental, investigational, or unproven are not covered under Cigna plans.

Coverage for Revision

Cigna may cover the revision, reversal, or conversion of a bariatric device or procedure under the following circumstances.

Mechanical or Medical Complications:

Band slippage or component malfunction that cannot be repaired
Severe or persistent gastrointestinal symptoms (e.g., persistent nausea, vomiting, reflux)
Major complications from previous surgery (e.g., stricture, ulceration, obstruction, or erosion)

Inability to Lose Weight:

If weight loss is not achieved in the absence of complications, revision or conversion may be covered when:

At least two years have passed since the original procedure
The patient continues to meet Cigna’s initial medical necessity criteria
The revision involves an approved, covered bariatric procedure

Revision or conversion could include the removal of a gastric band, conversion from Lap-Band to sleeve or bypass, or repair of a gastrojejunostomy.

Note: Revisions or reversals are not covered when weight loss failure is due to noncompliance with postoperative dietary or exercise recommendations, or for any other non-medical indication. This is yet another reason to follow all lifestyle modifications, including diet and exercise programs.

Does Cigna Have Provider or Facility Requirements?

Yes, choosing a designated in-network healthcare provider and/or facility may be required by your plan and can also help minimize out-of-pocket costs. Cigna also has two bariatric center designations, the 3 Star Quality designation and the Center of Excellence (COE) designation, which recognize facilities that meet rigorous standards for quality and cost efficiency. We perform all of our procedures in hospitals nationally certified as Centers of Excellence in Bariatric Surgery.

Additional Financial Considerations

As with all health insurance policies, you might still have certain out-of-pocket costs, which can include:

Deductible: The amount you must pay before insurance begins covering costs.
Coinsurance: A percentage of the procedure’s cost that remains your responsibility after the deductible.
Copayments: Fixed fees for specific services or visits.
Maximum Out-of-Pocket: Once you reach this limit, Cigna could cover 100% of eligible services for the rest of the year. But you have to reach this limit first, and those limits vary by policy.

Because benefits reset annually, it may be financially advantageous to complete your surgery within the same calendar year after meeting your deductible. Our team can help you estimate your potential costs and guide you through the preauthorization process.

Understanding healthcare benefits can feel complex and overwhelming, but you do have resources to help you navigate them. You can contact a Cigna Healthcare agent, talk to your Human Resources department, or have our office verify your benefits, explain plan-specific requirements, and coordinate the medical documentation needed for approval.

Remember, Cigna’s coverage policies provide general guidance, but your individual plan document is what ultimately determines your eligibility and benefits. If your insurance claim is denied, don’t lose hope. Sometimes, additional documentation or an extra step is all that’s needed. The team at Higa Bariatrics can help you review the decision and guide you through the appeal process if needed.

For those who decide to move forward without using insurance, we offer financing in the office through Care Credit and affordable cash-pay options through our partnership with Tucson Medical Center. Let us know if you have any questions; we’re happy to walk you through it! Learn more about our cash pay options here.