Blue Cross Requirements for Weight Loss Surgery

Blur Cross requirements, Logo

 

Blue Cross Requirements for Weight Loss Surgery

Weight loss surgery is considered an effective treatment of morbid obesity. While most of the Blue Cross insurance policies do cover weight loss surgery, not all of them do. Those that do cover the procedure have similar requirements to those of Blue Cross Blue Shield of Michigan. It is important that you meet these criteria in order to benefit from coverage of the insurance company for the entire process.

Requirements for Pre-Approval of Weight Loss Surgery with Blue Cross

Your Blue Cross insurance policy covers weight loss surgery unless it states specifically that it excludes it. In order to be pre-approved for the procedure you must meet the following requirements:

  • You need must be between the ages of 18 and 60 years old,
  • Exceptions to the age requirement can be made for patients under 18 years old if a letter is provided to the carrier by the physician stating that there is a dramatic risk for the patient’s health if surgery is withheld. Additionally, the letter should contain information regarding the physician’s evaluation of the patient’s mental health and have determined that the patient is prepared for such a surgery,
  • You need to be at a documented BMI level of over 40, or
  • You need to be at a documented BMI level of over 35 and suffer from a minimum of one comorbid condition such as:
    • Hypertension,
    • Obstructive sleep apnea,
    • Impaired glucose tolerance,
    • Type 2 diabetes,
    • Coronary artery disease.
  • Written evidence must show that other weight loss programs have failed to help the patient reduce or control their weight. These other programs must have been utilized for a minimum of twelve months consecutively to be considered. Some of these programs should have been prescribed by a physician other than the weight loss surgeon and may include:
    • Weight Watchers
    • Jenny Craig
    • Any medically supervised weight loss programs.

What Weight Loss Procedures Does Blue Cross Cover?

The weight loss procedures that Blue Cross covers include.

  • Lap Adjustable Gastric Bands,
  • Vertical Banded Gastroplasty
  • Duodenal Switch
  • Biliopancreatic bypass,
  • Gastric Sleeve Procedure
  • Gastric Bypass.

Procedures Blue Cross Does Not Cover

While Blue Cross does cover most of the weight loss procedures there are a few that they do not. These include:

  • Open and laparoscopic sleeve Gastrectomy
  • Open adjustable gastric banding
  • Laparoscopic and open vertical banded Gastrectomy

Other Considerations

While you go into the weight loss surgery with high hopes and expectations that it will be a success, there is always a possibility that it will not be as successful as you had hoped. If this is the case and you find a second surgery or procedure is needed, you might find that Blue Cross Blue Shield does provide coverage for a second surgery as long as you followed post-operative instructions and made life changes for success as well as turned to the bariatric surgeon and other sources for additional help. Blue Cross Blue Shield does cover a revision surgery if it is needed. They do require that certain documentation is provided by the physician including:

  • Reasons for failure of the surgery
  • Date and type of procedure
  • Evidence of patient’s compliance with all post-operative instructions including diet and exercise regimens

Blue Cross Blue Shield does not require that you seek surgery with an in-network surgeon. They do recommend that you utilize their in-network surgeons, however, in order to take advantage of their Center of Excellence. You can obtain a list of these professionals from your Blue Cross Blue Shield agent if you would like to consider these individuals for your surgery. Make sure that the individual that you do choose to work with is able to submit directly to Blue Cross Blue Shield for coverage of your procedure.