For individuals struggling with obesity and related health issues, bariatric surgery, also known as metabolic surgery, presents a potentially life-saving intervention when diet and exercise prove ineffective. Gastric sleeve, gastric bypass, and other weight loss surgical procedures can be life-saving for some patients. Blue Cross Blue Shield (BCBS), one of the largest healthcare insurers in the United States, offers various policies that cover bariatric surgery. Many Blue Cross Blue Shield insurance programs cover at least some types of weight loss surgery. However, understanding the specific coverage requirements of your BCBS plan is crucial, as these can vary significantly between states and individual plans.
What is Bariatric Surgery?
Bariatric surgeries are weight-loss surgeries. They also may be called metabolic surgery. Bariatric surgery is done only when diet and exercise haven't worked, or when you have major health problems because of your weight. These procedures encompass a range of surgical techniques aimed at facilitating weight loss by modifying the digestive system. Gastric sleeve surgery, for instance, involves removing approximately 80% of the patient’s stomach to create a smaller, sleeve-shaped organ that holds less food.
Blue Distinction Centers
Blue Cross and Blue Shield designates certain facilities as Blue Distinction Centers and Blue Distinction Centers+ specializing in bariatric surgery for their quality care, treatment expertise, and better patient results. Note: Designation as Blue Distinction Centers means these facilities' overall experience and aggregate data met objective criteria established in collaboration with expert clinicians' and leading professional organizations' recommendations. Individual outcomes may vary.
General Requirements for BCBS Coverage
Many BCBS plans have similar policies concerning weight loss surgery. While specific criteria may differ, some general requirements are commonly observed:
- Body Mass Index (BMI): Many BCBS plans will cover weight loss surgery for people with a BMI of 40 or greater. People with a BMI of 35 or greater may be eligible for coverage if they have a serious related condition. For instance, Anthem Blue Cross, which applies to more than 9 million lives across several states, does not cover weight loss surgery for people with a BMI of less than 35.
- Comorbidities: Individuals with a BMI of 35 or greater may qualify for coverage if they have serious health conditions related to obesity, such as type 2 diabetes, hypertension, sleep apnea, or heart disease.
- Prior Weight Loss Attempts: Most BCBS plans mandate documented attempts at weight loss through diet and exercise before considering bariatric surgery coverage.
- Psychological Evaluation: A psychological evaluation may be required to assess the patient's mental and emotional readiness for surgery and the lifestyle changes that follow.
- Nutritional Counseling: BCBS plans often require participation in a nutritional counseling program to educate patients about post-surgery dietary guidelines and ensure long-term success.
Variations in Coverage by State and Plan
It's important to recognize that BCBS coverage for bariatric surgery can vary significantly depending on the state and the specific plan. For example:
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- BCBS Michigan/Blue Care Network: 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: 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).
- BCBS Ohio and BCBS Kentucky: Like BCBS Ohio, Blue Cross Blue Shield Kentucky, which has nearly 2 million members, is operated by Anthem Blue Cross.
Therefore, it is essential to review your specific BCBS plan documents or contact a member services representative to understand the precise coverage criteria, limitations, and exclusions. Understand that some employers may opt for cheaper insurance plans that don’t include bariatric surgery. Some options, such as vagus (or vagal) nerve-blocking devices, typically are not covered.
Alternatives if BCBS Doesn't Cover Bariatric Surgery
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.
JourneyLite as an Alternative
Regardless of BCBS coverage for bariatric surgery, JourneyLite can help meet your weight loss goals. JourneyLite offers various surgical and non-surgical options in tune with our patients’ needs. Plus, we have flexible payment options through partnerships with several lenders. Programs like Anthem Blue Distinction Plus, Aetna Institute of Quality, and United Health Optum Bariatric Center of Excellence have recognized our quality of care. As a trusted provider, we have the information you’re looking for.
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