Friday, April 19, 2024

Does Bcbs Cover Bariatric Surgery

Does Blue Cross Blue Shield Cover Tummy Tucks

Bariatric Surgery: What You Need to Know

Abdominoplasty is considered cosmetic and not medically necessary for all applications. BCBSNC does not provide coverage for not medically necessary services or procedures.

When does Blue Cross Blue Shield cover lap band surgery?

You may automatically pre-qualify for Blue Cross or Blue Shield to cover your LAP-BAND Surgery if: You have a Body mass Index of 35 or greater and suffer from medical problems associated with obesity such as coronary heart disease, type 2 diabetes, sleep apnea or hypertension.

Are there any weight loss procedures that Blue Cross covers?

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

Does Anthem Blue Cross Blue Shield Cover Gastric Bypass

Yes, Anthem Blue Cross Blue Shield covers gastric bypass surgery, provided your health plan does not particularly exclude this procedure. The nationwide Anthem BCBS network recognizes obesity as a serious illness and offers some form of gastric bypass coverage under most of its health plans. Here are some of the key issues to keep in mind for your coverage.

  • Check whether your employer has opted-in for Anthem Blue Cross Blue Shield gastric bypass coverage.
  • If you have an individual policy, check the gastric bypass pre-approval requirements for your Anthem Blue Cross Blue Shield.
  • Consultation and recommendation from a qualified weight loss surgeon may be a mandatory requirement for pre-approval.
  • Both traditional gastric bypass and laparoscopic Roux-en-Y gastric bypass procedures are usually covered in Anthem BCBS.
  • Does Anthem Blue Cross Blue Shield cover mini gastric bypass? The answer is no, because this procedure is considered experimental.
  • Anthem BCBS gastric bypass should be performed at a bariatric center of excellence, but not necessarily by an in-network surgeon.

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Blue Cross Blue Shield Bariatric Surgery

People who are struggling with obesity often wonder: does Blue Cross Blue Shield cover weight loss surgery? The answer is yes, subject to fulfillment of the specific eligibility criteria set by your insurance provider. Bariatric surgery is recognized as an effective way to get rid of obesity and associated co-morbidities. As long as it can be shown that your procedure is a medical necessity, you can receive Blue Cross Blue Shield bariatric surgery coverage.

Types of weight loss surgery covered under BCBS

The Blue Cross Blue Shield weight loss surgery program offers coverage for a number of bariatric procedures. Gastric sleeve and gastric bypass are two of the leading procedures that are considered the safest and most definitive solutions to morbid obesity. The insurance companies in all the states cover these two procedures under Blue Cross Blue Shield bariatric surgery plans. In some cases, adjustable gastric band surgery is also covered.

Can a BCBS plan exclude bariatric surgery coverage?

Yes, some Blue Cross Blue Shield plans may not cover bariatric surgery. This will depend on the type of policy you have purchased. However, an exclusion of weight loss surgery from your BCBS plan should not discourage you from exploring various low cost self-pay options. Many patients who have inadequate or no insurance coverage for weight loss surgery now seek safe and affordable offshore medical tourism options.

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Does Blue Cross Michigan Require A Center Of Excellence

Blue Cross Michigan has strict guidelines for the requirement of a Center of Excellence.

  • The Center of Excellence should be certified by the American College of Surgeons as a level 1 bariatric surgery center.
  • The Center of Excellence should also hold a certification by the American Society for Bariatric Surgery as a bariatric surgery Center of Excellence.
  • Any bariatric surgeon that accepts Blue Cross Blue Shield of Michigan will know where the surgery has to take place.

States Where Insurance Is Required To Cover Bariatric Surgery

Insurance Cover For Weight Loss Surgery

Under the Affordable Care Acts Essential Health Benefits Benchmark Plans, 23 states require that all individual, family, and small group insurance plans cover bariatric surgery. Those states are:

Also under the ACA, in the following three states, bariatric surgery coverage must be offered in at least some policies:

  • Georgia, where a 1999 state law also mandates coverage for morbid obesity
  • Indiana, where a 2000 state law also mandates coverage for morbid obesity
  • Virginia, where a 2000 state law also mandates that coverage for morbid obesity must be offered in at least one plan by each state-regulated health insurer

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What Is A Letter Of Pre

A letter of pre-determination or pre-certification from your insurance company means their medical review department has decided, based on the information provided, that your surgery is medically necessary. But this does not mean they will cover your surgery. That depends on your individual insurance policy.

We will submit the necessary documentation to your insurance company. Please do not ask any other physician to submit anything directly to your insurance company. They can provide necessary documentation to us, and we will submit everything as the insurance company requires.

What Are The Requirements For Coverage Of Weight Loss Surgery

Requirements for surgery coverage will vary between each plan and the groups benefits. These general guidelines for pre-approval of bariatric surgery are standard, but specific requirements may be unique to your policy:

  • BMI: A body mass index or BMI of 40 or greater or a BMI of 35 or greater with one or more associated medical conditions is typically the first requirement for bariatric surgery candidates. Associated diseases may include diabetes, high blood pressure, severe sleep apnea, and more.
  • Obesity Diagnosis: A diagnosis of morbid obesity must be indicated in the patients medical records before surgery . Your primary care providers attestation and dated photographs may be accepted if morbid obesity has not been documented.
  • Supervised Weight Loss Program: Depending on the details of your plan, patients may be required to have documentation of physician-supervised weight loss attempts over the past 12 months. This may require proof of three, six, nine, or 12 months of participation. Some policies do not include this requirement. Other policies may ask for documentation of participation in other non-surgical weight loss programs like support programs such as Jenny Craig, Weight Watchers, and more.
  • Smoking Cessation: All patients must cease smoking at least eight weeks before surgery.

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Criteria For Coverage Of Surgery Costs

In order for Medicaid to cover the cost of your surgery and the associated surgeon visits, you must meet the requirements below.

  • Over the age of 13 for a female and 15 for a male.
  • Body Mass Index must be over 35 with at least one comorbidity.
  • Co-morbidities include sleep apnea, high blood pressure, high cholesterol, diabetes.
  • If you are under 21, you must have a Body Mass Index over 40 with at least one comorbidity.
  • A letter from your primary care physician stating that weight loss surgery is medically necessary.
  • Passes a psychological exam.
  • Documentation showing that the patient tried to manage their comorbidities with standard treatment but they were not successful.
  • The patient must complete and show documentation that he or she participated in a medically supervised weight loss program for 6 months and it happened within the last 12 months prior to surgery.
  • The patient must understand they will be required to change their diet and lifestyle after surgery.
  • Nutritional and psychological services must be available before and after surgery .
  • You Might Not Qualify for Weight Loss Surgery Coverage if:

    • Long-term steroid use

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    Make Sure You Meet The Requirements

    Does your insurance cover Bariatric surgery, and if not, what are the options?

    Before any health insurance policy will cover bariatric surgery, the patients must meet certain qualifications. The basic qualifications that all insurance companies require include:

    • The patient must be diagnosed by a doctor with a BMI of 40 or higher, or be at least 100 pounds overweight, or have a BMI of at least 35 and suffer from obesity-related comorbidity such as:
    • High blood pressure

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    How To Get Insurance To Pay For Bariatric Surgery By Demonstrating Medical Necessity

    Most insurance plans require that medical necessity be demonstrated before coverage is granted for weight-loss surgery. This means that in addition to your consultation with them, youll need to provide evidence that bariatric surgery is necessary for each patient. The exact criteria vary from one insurance provider to the next but typically include the following.

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    How Long Does It Take Bcbs To Approve Bariatric Surgery

    Blue Cross Blue Shield will take up to 30 days on average to approve your request for bariatric surgery. Therefore, when you are planning to undergo a weight loss surgery with insurance coverage, plan ahead of time, and keep track of the time it takes to complete the BCBS approval process.

    • Expedite the approval: To begin with, choose a hospital or bariatric surgeon that will help you meet the BCBS approval conditions quickly, and will follow up with them on your behalf. Prepare all the necessary documentation that BCBS may demand, such as health records, medical tests, diet and exercise report, and behavior modification class certificate .
    • BCBS appeal process: If Blue Cross Blue Shield does not approve your pre-authorization for bariatric surgery, you will still have an option to file an appeal. With guidance from your surgeon, be prepared to counter each argument they have made to deny your coverage request. Follow the precise rules of the BCBS appeal process, and make your appeal within the stipulated time.
    • Affordable surgery options: In a situation where you fail to get approved for bariatric surgery from BCBS and your appeal is also rejected, it still does not mean that you should deny yourself good health and a long life. Explore low cost bariatric surgery options, such as medical tourism with a trusted service provider. This will enable you to eliminate obesity and reclaim your health within your budget.

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    Procedures That Are Covered

    • Gastric Sleeve Surgery may be considered medically necessary as a surgical treatment option for patients with morbid obesity who meet the eligibility criteria for surgery.
    • Gastric bypass using a Roux-en-Y anastomosis may be considered medically necessary as an open or laparoscopic surgical treatment option for patients with morbid obesity who meet the eligibility criteria for surgery.
      • NOTE: This policy does not address Roux-en-Y gastric bypass performed primarily for the treatment of gastric reflux even though this condition may improve following a Roux-en-Y performed for the treatment of morbid obesity.
      • NOTE: Coverage is allowed for gallbladder removal at the time of a covered gastric bypass surgical procedure, either for documented gallbladder disease or for prophylaxis.
    • Biliopancreatic bypass without duodenal switch
    • Long limb gastric bypass procedures
    • Two-stage bariatric surgery procedures
    • Endoluminal procedures including but not limited to:
      • Long limb gastric bypass procedures
      • Long limb gastric bypass procedures
    • Endoscopic procedures including but not limited to sclerotherapy of the stoma
    • Transoral ROSE procedure
    • Any procedure, including the covered procedures listed above, will NOT be covered if they are considered experimental, investigational and/or unproven for the treatment of any condition other than morbid obesity, including but not limited to metabolic syndrome, gastroesophageal reflux disease and sleep apnea

    What Will My Out Of Pocket Expenses Be

    What Bcbs Plan Covers Bariatric Surgery

    Once again, exact coverage will depend your group benefits, so we suggest that you either call BCBS Alabama directly or speak to your HR department at work. At your office consult, you will meet with our Bariatric Coordinator who will go over your benefits and obligations.

    Remember that your plan will most likely have calendar year deductibles, co-insurances and out of pocket maximums that reset on January 1. If you are approaching the end of the year, your actual out of pocket expenses may be lower if you have already paid for medical treatment earlier in the year.

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    How To Get Financing For Weight Loss Surgery

    Your doctor can first contact your insurance company on your behalf. Also, giving up on surgery in the middle of the process doesnt change anything. Your own doctor has a lot of say over how your insurance company approves things. Second, you can talk to your companys Human Resources department about this problem.

    You can always call your insurance company yourself, which is always a valid option. And make sure you have a Summary Plan Statement. Also, if you meet all of the other requirements, Medicare will pay for the following procedures:

    • Sleeve gastric surgery
    • Surgery to put on a belly band,
    • Open or laparoscopic biliopancreatic diversion with duodenal switch

    What should you do if bariatric surgery is not covered by your insurance? If your insurance doesnt cover weight loss surgery despite what weve listed above, its probably not in your policy. First, you should be sure by asking your surgeon. It will get in touch with your insurance company at no cost to you. Dont worry, insurance companies are in touch with surgeons and their offices. So, they have a very good idea of how the process works.

    What Are The Requirements For Coverage

    Requirements will vary between plans and groups. The following are general guidelines for pre-approval of bariatric surgery:

    • A body mass index or BMI of 40 or more or a BMI of 35 or more with one or more diseases associated with morbid obesity. These diseases may include diabetes, high blood pressure, severe sleep apnea and more.
    • A diagnosis of morbid obesity must have been placed in the patients medical records prior to surgery . Your primary care physicians attestation as well as dated photographs may be accepted if morbid obesity has not been documented officially in medical records.
    • Patients should have documentation that they have participated in a doctor-supervised weight loss program within the past 12 months. Patients may need to show proof of three, six, nine or 12 months of participation depending on their plan.
    • Patients must have documentation showing participation in non-surgical weight loss programs. These may include support programs such as Jenny Craig, Weight Watchers and more.
    • Patients will need to stop smoking at least eight weeks before surgery date.

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    Does Blue Cross Blue Shield Arizona Cover Bariatric Surgery

    Blue Cross Blue Shield of Arizona is the largest health insurance in the state of Arizona and offers a wide variety of PPO and HMO policies. As with most insurance companies, they have a relatively straightforward, but stringent set of criteria for covering bariatric surgery. However, bariatric surgical coverage varies between policies and even if someone you know has bariatric coverage with BCBS Arizona, that does not mean that your policy will. Therefore, the first step is to speak to BCBS to understand a) whether you have coverage for bariatric surgery and b) what the requirements are for coverage.

    Does Blue Cross Blue Shield Cover Weightloss Surgery

    Does Medicare cover bariatric surgery?

    Does Blue Cross Blue Shield Cover Weightloss Surgery?

    Does Blue Cross Blue Shield Cover Weightloss Surgery?

    Does Blue Cross Blue Shield Cover Weightloss Surgery? On average, it will take Blue Cross Blue Shield 30 days to approve your request for bariatric surgery. So, if you want to have weight loss surgery that is covered by your insurance, you should plan ahead and keep track of how long it takes to get BCBS approval.

    First, choose a hospital or bariatric surgeon who can help you meet the BCBS approval conditions quickly and will follow up with them on your behalf. Prepare all the paperwork that BCBS may need, such as health records, medical tests, a report on your diet and exercise, and a certificate from a class on changing your behavior .

    The BCBS appeals process says that you can still file an appeal if Blue Cross Blue Shield does not approve your pre-authorization for bariatric surgery. With help from your surgeon, be ready to respond to every reason theyve given to turn down your request for coverage. Follow the exact rules of the BCBS appeals process and file your appeal within the time limit.

    If BCBS doesnt approve your bariatric surgery and your appeal is also denied, that doesnt mean you have to deny yourself good health and a long life. Check out options for low-cost bariatric surgery, like medical tourism with a reputable service provider. This will help you lose weight and get your health back without going over your budget.

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    If Your Policy Does Not Cover It: Seek Partial Coverage

    You may be able to get part of the costs paid for by insurance even if weight loss surgery isnt covered. Its all about how your doctor and hospital submit your claims to your insurance company.

    For example, there are many non-bariatric surgery reasons for your doctor to recommend:

    • Cardiology exam
    • Psychological exam

    These are ordered for many reasons other than bariatric surgery and may be covered as a result. If your doctor submits one of these claims using a weight loss surgery CPT code , your insurance is unlikely to cover it. But if your doctor uses a general CPT code, it probably will be covered.

    While this may sound sneaky, it is an ethical practice. After all, these tests will be beneficial regardless of whether you move forward with surgery.

    Anthem Weight Loss Surgery How To Avoid A Denial

    Your Anthem Blue Cross Blue Shield weight loss surgery insurance coverage depends on several factors, all of which are reviewed below.

    First, try our insurance tool to quickly check your insurance coverage:

    Read and click below for additional weight loss surgery insurance details.

    • 35+ Body Mass Index
    • Documentation of failed diet attempts
    • Psychological evaluation

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