Obesity is a significant health concern, with projections estimating that nearly half of adults will be obese by 2030. Clinically severe obesity, resulting from persistent and uncontrollable weight gain, poses a significant threat to life and is associated with numerous health complications. While lifestyle changes and medical interventions are the first line of treatment, bariatric surgery can be a viable option for individuals who have not achieved sustainable weight loss through non-surgical methods.
Blue Cross Blue Shield (BCBS) is a major health insurance provider in the United States, offering a variety of plans, including Medicare, group, individual, and family options, as well as HMO and PPO plans. However, bariatric surgery coverage can vary significantly between these plans. This article aims to provide a comprehensive overview of Anthem Blue Cross Blue Shield's weight loss surgery coverage, including eligibility requirements, covered procedures, and important considerations.
Does Anthem Blue Cross Blue Shield Cover Weight Loss Surgery?
The short answer is yes, many Anthem BCBS policies cover weight loss surgery. Obesity Coverage strongly believes that morbid obesity is a disease and every insurance company should cover these life saving procedures. Fortunately, many insurance companies recognize the serious health threats of obesity and do cover weight loss surgery as long as you meet the qualification requirements. However, it's crucial to confirm whether your specific policy includes this coverage, as employers can opt-out of weight loss surgery coverage to save on premiums. Contact Anthem directly at 1-866-293-2892 to inquire about your policy's coverage for CPT Code 43775, which is the medical billing code for gastric bypass surgery.
Eligibility Requirements for Bariatric Surgery Coverage
BCBS Nevada and all other insurance companies want to ensure that surgery is absolutely necessary before approving coverage. Therefore, they require documentation to that effect. To qualify for bariatric surgery coverage under Anthem BCBS, you must generally meet the following criteria:
Body Mass Index (BMI): A BMI of 40 or greater, or a BMI of 35 or greater with one or more obesity-related co-morbid conditions is typically required. These co-morbid conditions may include:
Read also: Benefits of couples massage detailed
- Diabetes mellitus, Type II
- Cardiovascular disease
- Hypertension
- Life-threatening cardio-pulmonary problems (e.g., severe obstructive sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy)
Morbid Obesity Diagnosis: A diagnosis of morbid obesity must have been established for a certain period before surgery, potentially up to three years.
Participation in a Weight Loss Program: Active participation in a weight loss program for at least 3-6 months may be required.
Pre-operative Evaluations and Clearances: Completion of pre-operative medical and mental health evaluations and clearances is necessary.
Nutritional Counseling: Pre-operative nutritional counseling with a Registered Dietitian is typically required.
Patient Education: Pre-operative education addressing the risks, benefits, realistic expectations, and the need for long-term follow-up and adherence to behavioral modifications is essential.
Read also: How digestive health affects weight loss
Medical Necessity: A letter from your primary care physician demonstrating the medical necessity of bariatric surgery may be required.
Non-Surgical Weight Loss History: You may need to provide documentation of failed nonsurgical diet and exercise programs.
Covered Bariatric Procedures
If your Anthem BCBS policy covers bariatric surgery, major, proven procedures like gastric sleeve and gastric bypass are typically covered. The duodenal switch, while less common, may also be covered. Revisions to previous bariatric procedures may be covered on a case-by-case basis, especially if complications arise. Most commonly, the removal of a Lap-Band and revision to a gastric sleeve is a covered procedure.
Anthem BCBS considers Lap Band fills a medical necessity when required to meet the proper level of weight loss. This is true only if you’ve had a previous adjustable gastric banding procedure that met all of the criteria laid out for that procedure. Revisions are covered if there is documentation of a failure secondary to a surgical complication.
Procedures Not Typically Covered
Procedures considered experimental, such as the Mini Bypass, may not be covered. Some options, such as vagus (or vagal) nerve-blocking devices, typically are not covered. Endoluminal reoperative bariatric procedures including, but not limited to, transoral outlet reduction (TORe) or restorative obesity surgery endoluminal (ROSE) are considered not medically necessary for all indications. Bariatric surgical procedures including, but not limited to, laparoscopic adjustable gastric banding are considered not medically necessary for individuals with a BMI below 35 kg/m². Endoscopically placed percutaneous aspiration tube (such as AspireAssist®).
Read also: Weight Loss Meds & BCBS
Center of Excellence Requirement
The surgery must take place at a Center of Excellence. However, you do not have to use an in-network surgeon. But, the costs will be higher for you if you use an out of network doctor. They will also need to have privileges to perform the weight loss surgery at the accredited Center of Excellence.
Understanding Your Out-of-Pocket Expenses
Your out-of-pocket expenses will depend on your benefits, which can be found in the coverages and exclusions section of your insurance documents. Typically, Anthem BCBS customers will be subject to a co-pay, deductible, and maximum out-of-pocket expense. Be mindful that all of these reset on January 1.
What to Do if Your Claim is Denied
There are times when Anthem BCBS Nevada may deny preapproval for a bariatric procedure. Many times, this is because of a clerical error in the application. Therefore, the first step is to get a reason for the denial in writing.
The Importance of Pre-Approval
Pre-approval for coverage does not automatically guarantee payment. There are various reasons that the insurance company can deny your claim. Once again, many of these are administrative mistakes that are easily fixed. The insurance company wants to verify that the procedure is necessary. Still, there is a gray area, and we help you navigate those intricacies and questions to make the process as easy as possible.
Blue Cross Blue Shield Plans and Variations
Blue Cross Blue Shield is the largest health insurance company in the United States and provides a wide range of plans including Medicare, group, individual, and family. Blue Cross Blue Shield also offers a number of HMO and PPO options. Each of these plans can vary drastically, despite being underwritten by the same insurance company. For example, HMO plans will require a primary care physician referral for any specialist visits, while PPO customers can choose their own doctor.
Blue Cross Blue Shield Companies and Coverage Expansion
With 39 independent, community-based and locally operated Blue Cross and Blue Shield companies, both Blue Shield LAP-BAND Surgery and Blue Cross LAP-BAND Surgery plans may have slightly different coverage and requirements for weight loss surgery.BCBS Michigan/Blue Care Network, which covers nearly 5 million lives, has revised its policy on bariatric surgery to expand coverage for patients with a BMI of 30 to 35 with type 2 diabetes. Premera Blue Cross, which covers nearly 2.5 million lives, has also revised its policy and expanded coverage for patients with a BMI of 30 to 35 with type 2 diabetes (although they do have some glycemic control restrictions, requiring a hemoglobin A1c level above 7).
Non-BCBS Coverage Options
Even if your BCBS plan doesn’t cover your bariatric surgery, there are still affordable options to help you achieve your goals. Finding a different insurer that does cover weight loss surgery is one possibility.
Lifestyle Changes and Bariatric Surgery
Bariatric procedures can be an aid in achieving weight loss, but successful and sustained weight loss requires that individuals are compliant with significant life-long lifestyle changes.
Recommendations for Optimizing Surgical Outcomes
In 2021, the ASMBS published preoperative recommendations meant to minimize the risk of complications and optimize surgical outcomes by managing modifiable risk factors (Carter, 2021). The society defined preoperative optimization as active risk mitigation, by actively identifying and potentially delaying surgery until a specific goal is met. These recommendations include smoking cessation and achieving adequate glycemic control prior to surgery. The society also recommends a thorough evaluation by an individual’s primary care physician as well as assessing behavior patterns such as eating and physical activity patterns.
The Evolving Criteria for Bariatric Surgery
In 2022, the ASMBS and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) published a guideline on the indications for metabolic and bariatric surgery. The societies note that the standard for selection criteria for bariatric surgery (BMI ≥ 40 kg/m2 or BMI ≥35 kg/m2 with co-morbidities) proposed by the NIH in 1991 has evolved. The societies propose less importance on strict BMI categories, arguing that bariatric and metabolic surgery be expanded to include all classes of obesity.