Unlock the Secrets of Blue Cross Blue Shield Weight Loss Surgery Coverage Now!

Obesity is a significant health concern in the United States, with an estimated one in three American adults affected. Blue Cross Blue Shield (BCBS) recognizes the seriousness of this issue and offers various programs and coverage options to support members in achieving their weight loss goals. Bariatric surgery, also known as metabolic surgery, is one such option for individuals who meet specific criteria. This article provides a comprehensive overview of BCBS's requirements for weight loss surgery, including eligibility, covered procedures, and pre- and post-operative care.

BCBS Weight Management Programs and Resources

BCBS offers a range of resources to help members manage their weight and improve their overall health. These include:

Personalized Action Plans: BCBS provides tools to help members create personalized action plans and track their progress toward their health goals.
Wellness Deals: Members can access discounts on various national health and wellness brands through Blue365®.
Registered Dietitians: BCBS connects members with registered dietitians who can provide personalized meal plans and nutritional guidance.
Weight Management Programs: Eligible members can participate in weight management programs like Livongo®, which offers digital scales and ongoing support. To be eligible for the Weight Management Program by Livongo®, members must have a pediatric pharmacy or medical claim in the 85th percentile or higher within the last three years or an adult pharmacy or medical claim with a BMI of 25 or higher within the last three years. Members living overseas must have a valid APO, DPO or FPO address.
Weight-Loss Medications: BCBS covers FDA-approved weight-loss drug prescriptions for eligible members who meet specific criteria and obtain prior approval. Beginning January 1, 2025, the tiers for some weight loss GLP-1 drugs will change for members with FEP Blue Standard® and FEP Blue Basic® plans.
Bariatric Surgery: BCBS covers procedures to treat morbid obesity for members who meet eligibility criteria and obtain prior approval.

Eligibility Criteria for Bariatric Surgery

BCBS considers bariatric surgery a treatment option for individuals with class III obesity who have not achieved satisfactory weight loss through conservative measures such as diet and exercise. Class III obesity, previously known as morbid obesity, is defined as:

A body mass index (BMI) of 40 kg/m2 or greater.
A BMI of 35 kg/m2 or greater with associated complications, including but not limited to diabetes, hypertension, cardiopulmonary conditions, or obstructive sleep apnea.

It is important to note that the American Society for Metabolic & Bariatric Surgery (ASMBS) suggests that the BMI be adjusted for ethnicity, with Asian American adults having a lower BMI cutoff for obesity.

Pre-Surgical Requirements

BCBS typically requires patients to meet certain pre-surgical requirements to ensure they are prepared for the procedure and committed to long-term lifestyle changes. These requirements may include:

Read also: Does BCBS Cover Weight Loss?

Mental Health Evaluation: A consultation with a licensed mental health professional within 12 months before the surgery to assess the patient's psychological readiness and identify any potential issues that may affect post-operative success.
Supervised Preoperative Program: Active participation in a preoperative program supervised by a physician, physician’s assistant, nurse practitioner/advanced practice nurse, or registered dietician.
Surgical Preparatory Program: Completion of a surgical preparatory program to educate the patient about the procedure, risks, and expected outcomes.
Documentation: Inclusion of documentation supporting the medical necessity criteria in the prior authorization request.

Covered Bariatric Surgical Procedures

BCBS covers various bariatric surgical procedures, including:

Adjustable Gastric Banding: A gastric band is placed around the exterior of the stomach, connected to a reservoir that is implanted subcutaneously. Saline injections into the reservoir adjust the band's diameter, progressively narrowing the stoma to induce weight loss or expanding it if complications arise. The first to receive the FDA approval was the LAP-BAND® (original applicant, Allergan, BioEnterics, Carpinteria, CA; now Apollo Endosurgery, Austin, TX). "The LAP-BAND system is indicated for use in weight reduction for severely obese patients with a BMI of at least 40 or a BMI of at least 35 with 1 or more severe comorbid conditions, or those who are 100 lb or more over their estimated ideal weight according to the 1983 Metropolitan Life Insurance Tables (use the midpoint for medium frame). It is indicated for use only in severely obese adult patients who have failed more conservative weight-reduction alternatives, such as supervised diet, exercise, and behavior modification programs. The second adjustable gastric banding device approved by the FDA through the premarket approval process is the REALIZE® model (Ethicon Endo-Surgery, Cincinnati, OH). "The [REALIZE] device is indicated for weight reduction for morbidly obese patients and is indicated for individuals with a BMI of at least 40 kg/m2, or a BMI of at least 35 kg/m2 with 1 or more comorbid conditions.
Sleeve Gastrectomy: The majority of the greater curvature of the stomach is removed, creating a tubular stomach. This can be performed as a standalone procedure or in combination with a malabsorptive procedure.
Mini-Gastric Bypass: A modification of the gastric bypass in which the stomach is divided using a laparoscopic approach.
Vertical Banded Gastroplasty: The stomach is divided vertically, with a band stapled around the top portion of the stomach.
Roux-en-Y Gastric Bypass (RYGB): A small stomach pouch is created, and the remaining stomach remnant is stapled off from the pouch. The intestine is divided into two limbs, with the pouch anastomosed to a Roux limb of jejunum and the pancreaticobiliary limb anastomosed more distally to the Roux limb.
Biliopancreatic Diversion (BPD): Consists of a subtotal gastrectomy and diversion of the biliopancreatic juices into the distal ileum by a long Roux-en-Y procedure.
Duodenal Switch (DS): A variant of the BPD in which a sleeve gastrectomy is performed along the vertical axis of the stomach, preserving the pylorus and initial segment of the duodenum.
Laparoscopic Gastric Plication: Laparoscopic placement of sutures over the greater curvature (laparoscopic greater curvature plication) or anterior gastric region (laparoscopic anterior curvature plication) to create a tube-like stomach.

Devices

AspireAssist® Weight Loss Therapy System: Consists of a gastronomy tube and a "gravity" flow director system through which patients aspirate gastric contents directly into the toilet about 20 to 30 minutes after consumption of a meal. The system was FDA-approved in June 2016 and is intended for adults who are at least 22 years old and have a BMI of 35.0-55.0 kg/m2 who have failed to achieve and maintain weight loss with non-surgical weight loss therapy.
Duodenal-jejunal Sleeve: These devices are designed to block absorption from the proximal small intestine.
Primary Obesity Surgery, Endoluminal (POSE): An endoscopic gastroplasty that uses tissue anchors to reduce the size of the stomach and its ability to stretch to accommodate a meal.
Transpyloric Shuttle (TPS): Is intended to treat obesity by slowing gastric emptying. The device consist of a large spherical bulb connected to a smaller cylindrical bulb by a flexible tether. A clinician endoscopically places the device in the patient’s stomach, where it self-positions across the pylorus to slow gastric emptying. The device is temporary and intended for endoscopic removal after 12 months.
Intragastric Balloons: Labeled indication: For use in obese adults (BMI, 30 to 40 kg/m2) who have failed weight reduction with diet and exercise and have no contraindications. Maximum placement time is 6 mo. Balloon is encased in a capsule. The capsule is swallowed and begins to dissolve after exposure to fluids in the stomach. After verification of capsule placement in the stomach, the balloon is filled with a gas mixture. AspireAssist System®, manufactured by Aspire Bariatrics, has a PMA date of June 2016. ORBERA® intragastric balloon system, manufactured by Apollo Endosurgery, has a PMA date of August 2015.

Procedures Not Considered Medically Necessary

BCBS may not consider certain procedures medically necessary, including:

Bariatric surgical procedures for individuals with a BMI below 35 kg/m².
Endoluminal reoperative bariatric procedures, such as transoral outlet reduction (TORe) or restorative obesity surgery endoluminal (ROSE).
Endoscopically placed percutaneous aspiration tubes (such as AspireAssist®) when the criteria are not met.
Initial and reoperative bariatric procedures when the specified criteria are not met.

Blue Distinction Centers for Bariatric Surgery

BCBS recognizes facilities that demonstrate expertise in bariatric surgery through its Blue Distinction Centers program. Blue Distinction Centers and Blue Distinction Centers+ specializing in bariatric surgery offer quality care, treatment expertise, and better patient results. Designation as a Blue Distinction Center means that these facilities' overall experience and aggregate data met objective criteria established in collaboration with expert clinicians' and leading professional organizations' recommendations. However, individual outcomes may vary.

Post-Operative Care and Considerations

BCBS emphasizes the importance of post-operative care and long-term lifestyle changes for successful weight loss after bariatric surgery. This includes:

Treatment Plan: A comprehensive treatment plan that addresses the pre- and post-operative needs of the individual undergoing bariatric surgery.
Lifestyle Changes: Compliance with significant life-long lifestyle changes, including dietary modifications, regular exercise, and behavioral interventions.
Monitoring and Follow-Up: Regular monitoring for potential complications and metabolic adverse events, especially in malabsorptive procedures.

Revision and Conversion Procedures

Surgical repair/correction or reversal following gastric bypass and gastric restrictive procedures is considered medically necessary when there is documentation of a surgical complication related to the original surgery, such as a fistula, obstruction, erosion, disruption/leakage of a suture/staple line, band herniation, stricture, documented gastroesophageal reflux disease (GERD) or pouch enlargement/dilation. Revision/ conversion indications apply to the procedures listed under criteria B for the initial procedure.

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