Blue Cross Blue Shield Weight Loss Surgery Coverage Requirements: An In-Depth Guide

Obesity, particularly clinically severe obesity, poses a significant threat to health, increasing the risk of various complications and even mortality. Blue Cross Blue Shield (BCBS) offers coverage for surgical and other treatments for clinically severe obesity, also known as class III obesity or morbid obesity. This article delves into the specific requirements and considerations for BCBS coverage of weight loss surgery.

Understanding Clinically Severe Obesity

Clinically severe obesity results from persistent and uncontrollable weight gain, posing a present or potential threat to life. The National Institutes of Health (NIH) defines a health risk as an increase of 20 percent or more above an individual’s ideal body weight. By 2030, it is predicted that nearly one in two adults will be obese and nearly one in four adults will be categorized as having severe obesity.

Class III obesity, formerly referred to as morbid obesity, is defined as a body mass index (BMI) greater than 40 kg/m2 or a BMI greater than 35 kg/m2 with associated complications including, but not limited to, diabetes, hypertension, cardiopulmonary conditions or obstructive sleep apnea. Class III obesity results in a very high risk for weight-related complications, such as diabetes, hypertension, obstructive sleep apnea, and various types of cancers (for men: colon, rectal, and prostate; for women: breast, uterine, and ovarian), and a shortened life span. Per the Centers for Disease Control and Prevention (CDC), obesity is also frequently classified into the categories of Class 1: BMI of 30 to < 35 kg/m2; Class 2: BMI of 35 to < 40 kg/m2; and Class 3: BMI of 40 kg/m2 or higher.

Initial Steps: Lifestyle Changes and Medical Interventions

The first line treatment of clinically severe obesity is dietary and lifestyle changes, including regular exercise. Weight loss is accomplished when there is a caloric deficit, that is, calories out must be greater than calories in. This can be accomplished by decreasing the calories ingested with some form of dietary restriction and by increasing the calories expended through increased physical activity. All available therapies (dietary, behavioral, pharmacologic, and surgical) help with weight loss by changing the calories ingested, absorbed, or expended. Weight loss can result in a reduction of comorbidities, a decrease in mortality and an increase in the quality of life.

The United States Preventive Services Task Force (USPSTF) statement from 2018 recommends that adults with a BMI of 30 or higher be referred to intensive, multicomponent behavioral interventions (Grade B). Most of the intensive behavioral weight loss interventions considered by the USPSTF lasted for 1 to 2 years, and the majority had 12 or more sessions in the first year. One-third of the interventions had a “core” phase (ranging from 3-12 months) followed by a “support” or “maintenance” phase (ranging from 9-12 months). Most behavioral interventions encouraged self-monitoring of weight and provided tools to support weight loss or weight loss maintenance (eg, pedometers, food scales, or exercise videos). Similar behavior change techniques and weight loss messages were used across the trials. Programs which combined behavioral interventions and pharmacotherapy reported greater success.

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The American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) 2016 clinical practice guidelines for medical care in obese individuals recommend lifestyle therapy which includes healthy meals with reduced calories and physical therapy for those suffering with obesity with associated comorbidities or those at risk for developing obesity related comorbidities. Behavioral interventions that enhance adherence to prescriptions for a reduced-calorie meal plan and increased physical activity (behavioral interventions can include: self-monitoring of weight, food intake, and physical activity; clear and reasonable goal-setting; education pertaining to obesity, nutrition, and physical activity; face-to-face and group meetings; stimulus control; systematic approaches for problem solving; stress reduction; cognitive restructuring [i.e., cognitive behavioral therapy], motivational interviewing; behavioral contracting; psychological counseling; and mobilization of social support structures).

Bariatric Surgery: A Potential Solution

The fundamental basis for bariatric surgery for the purpose of accomplishing weight loss is the determination that severe obesity is a disease associated with multiple adverse effects on health which can be reversed or improved by successful weight loss in patients who have been unable to sustain weight loss by non-surgical means. Surgery for clinically severe obesity (bariatric surgery) falls into two categories: gastric restrictive procedures and malabsorptive procedures.

Types of Bariatric Procedures

Surgery for clinically severe obesity (bariatric surgery) falls into two categories: gastric restrictive procedures and malabsorptive procedures.

1. Gastric Restrictive Procedures:
   • These procedures create a small pouch in the stomach, making the individual feel full sooner and reducing food intake.
   • Adjustable gastric banding involves placing a band around the upper portion of the stomach to reduce its size.
   • Examples include Adjustable gastric banding (CPT code 43770). Adjustable gastric banding has been widely used in Europe. Food and Drug Administration (FDA) for marketing in the United States. 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 (SG; CPT code 43775) is an alternative approach to gastrectomy that can be performed on its own or in combination with malabsorptive procedures (most commonly biliopancreatic diversion [BPD] with duodenal switch [DS]). In this procedure, the greater curvature of the stomach is resected from the angle of His to the distal antrum, resulting in a stomach remnant shaped like a tube or sleeve. The pyloric sphincter is preserved, resulting in a more physiologic transit of food from the stomach to the duodenum and avoiding the dumping syndrome (overly rapid transport of food through the stomach into intestines) seen with distal gastrectomy. This procedure is relatively simple to perform and can be done as an open or laparoscopic procedure. Some surgeons have proposed the SG as the first in a 2-stage procedure for very high-risk patients.
   • Vertical-banded gastroplasty (VBG; CPT code 43842) was formerly one of the most common gastric restrictive procedures performed in the United States but has now been replaced by other restrictive procedures due to high rates of revisions and reoperations. In this procedure, the stomach is segmented along its vertical axis. In order to create a durable reinforced and rate-limiting stoma at the distal end of the pouch, a plug of stomach is removed, and a propylene collar is placed through this hole and then stapled to itself. Because the normal flow of food is preserved, metabolic complications are uncommon. Complications include esophageal reflux, dilation, or obstruction of the stoma, with the latter two requiring reoperation. Dilation of the stoma is a common reason for weight regain.
2. Malabsorptive Procedures:
   • These procedures rearrange the connections between the stomach and intestines, causing food to be poorly digested and incompletely absorbed.
   • Weight loss is due to malabsorption without necessarily requiring dietary modification.
   • The BPD procedure (also known as the Scopinaro procedure; CPT code 43847), developed and used extensively in Italy, was designed to address drawbacks of the original intestinal bypass procedures that have been abandoned due to unacceptable metabolic complications. Many complications were thought to be related to bacterial overgrowth and toxin production in the blind, bypassed segment. In contrast, BPD consists of a subtotal gastrectomy and diversion of the biliopancreatic juices into the distal ileum by a long Roux-en-Y procedure. A 50- to 100-cm “common tract” is where food from the alimentary tract mixes with biliopancreatic juices from the biliary tract. Food digestion and absorption, particularly of fats and starches, are therefore limited to this small segment of bowel, creating selective malabsorption. Many potential metabolic complications are related to BPD, including, most prominently, iron deficiency anemia, protein malnutrition, hypocalcemia, and bone demineralization. Protein malnutrition may require treatment with total parenteral nutrition.
   • CPT code 43845, which specifically identifies the duodenal switch (DS) procedure, was introduced in 2005. The DS procedure is a variant of the BPD previously described. In this procedure, instead of performing a distal gastrectomy, a SG is performed along the vertical axis of the stomach. This approach preserves the pylorus and initial segment of the duodenum, which is then anastomosed to a segment of the ileum, similar to the BPD, to create the alimentary limb. Preservation of the pyloric sphincter is intended to ameliorate the dumping syndrome and decrease the incidence of ulcers at the duodeno-ileal by providing a more physiologic transfer of stomach contents to the duodenum. The SG also decreases the volume of the stomach and decreases the parietal cell mass.
   • Variations of gastric bypass procedures have been described, consisting primarily of long-limb Roux-en-Y procedures (CPT code 43847), which vary in the length of the alimentary and common limbs. For example, the stomach may be divided with a long segment of the jejunum (instead of ileum) anastomosed to the proximal gastric stump, creating the alimentary limb. The remaining pancreaticobiliary limb, consisting of stomach remnant, duodenum, and length of proximal jejunum, is then anastomosed to the ileum, creating a common limb of variable length in which the ingested food mixes with the pancreaticobiliary juices. While the long alimentary limb permits absorption of most nutrients, the short common limb primarily limits absorption of fats. The stomach may be bypassed in a variety of ways, i.e., either by resection or stapling along the horizontal or vertical axis. Unlike the traditional gastric bypass, which is a gastric restrictive procedure, these very long-limb Roux-en-Y gastric bypasses combine gastric restriction with some element of malabsorptive procedure, depending on the location of the anastomoses.
   • CPT code 43645 was introduced in 2005 to specifically describe a laparoscopic malabsorptive procedure.
3. Combined Procedures:
   • Roux-en-Y Gastric bypass (RYGB): Through an open or laparoscopic approach, a small stomach pouch is created, and the remaining stomach remnant stapled off from the pouch. The intestine is divided into two limbs. The pouch is anastomosed to a Roux limb of jejunum. The pancreaticobiliary limb, consisting of stomach remnant, duodenum, and proximal jejunum, is anastomosed more distally to the Roux limb. The original gastric bypass surgeries were based on the observation that postgastrectomy patients tended to lose weight. The current procedure (CPT code 43846) involves both a restrictive and a malabsorptive component, with the horizontal or vertical partition of the stomach performed in association with a Roux-en-Y procedure (i.e., a gastrojejunal). Thus, the flow of food bypasses the duodenum and proximal small bowel. The procedure may also be associated with an unpleasant “dumping syndrome,” in which a large osmotic load delivered directly to the jejunum from the stomach produces abdominal pain and/or vomiting. The dumping syndrome may further reduce intake, particularly in “sweets eaters.” Surgical complications include leakage and operative margin ulceration at the anastomotic site. Because the normal flow of food is disrupted, there are more metabolic complications than with other gastric restrictive procedures, including iron deficiency anemia, vitamin B12 deficiency, and hypocalcemia, all of which can be corrected by oral supplementation. Another concern is the ability to evaluate the “blind” bypassed portion of the stomach. Note: In 2005, CPT code 43846 was revised to indicate that the short limb must be 150 cm or less, compared with the previous 100 cm. This change reflects the common practice in which the alimentary (i.e., jejunal limb) of a gastric bypass has been lengthened to 150 cm.

Patient Selection and Requirements

According to the NIH, weight loss surgery candidates include those individuals suffering from the complications of extreme obesity, for whom conservative medical therapy has failed. Possible surgical candidates are those with severe obesity, defined as a body mass index (BMI) of 40 or greater, or 35 or greater with other medical complications.

Blue Cross Blue Shield generally considers bariatric surgery medically necessary for individuals who meet specific criteria. These typically include:

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• A BMI of 40 kg/m² or greater.
• A BMI of 35 kg/m² or greater with at least one significant obesity-related comorbidity, such as type 2 diabetes, hypertension, sleep apnea, or heart disease.
• Documented failure of previous non-surgical weight loss attempts, such as diet, exercise, and behavioral modification programs.
• Psychological evaluation and clearance to ensure the individual is mentally prepared for the lifestyle changes required after surgery.
• Commitment to long-term follow-up care, including dietary and exercise recommendations.
• Patient has been evaluated by an eligible licensed mental health professional within 12 months prior to the surgery.
• Patient has actively participated in a preoperative program supervised by a physician, physician’s assistant, nurse practitioner/advanced practice nurse, or registered dietician.
• Patient has completed a surgical preparatory program.

BMI Considerations

BMI is the generally accepted measure of determining the degree of overweight or obesity, being easy to measure, reliable, and correlated with percentage of body fat and body fat mass. However, BMI may overestimate or underestimate the degree of adiposity in certain individuals (for example, muscular persons or in older persons due to loss of muscle mass associated with aging respectively). While some data (American Diabetes Associates, 2022; Mui, 2018) suggests that at-risk BMI for overweight and obesity may be suboptimal for defining diabetes risk in Asian Americans (with a proposal for using a lower BMI cut for diabetes screening), high-quality prospective data is still needed to confirm that lower BMI thresholds are appropriate as a method of identifying candidates for bariatric surgery. The American Society for Metabolic & Bariatric Surgery (ASMBS) recommends the BMI be adjusted for ethnicity, with Asian American adult’s BMI cutoff for obesity be lowered. This recommendation is graded D: primary based on expert opinion (Mechanick, 2019). Furthermore, determining the optimal BMI cut point for identifying Asian Americans is complex given that there is tremendous heterogeneity among the Asian American subgroups (Hsu, 2015; Jih, 2014). Additional research will help to further elucidate current findings on the relationship between BMI and incident diabetes in Asian Americans. … while some data exist for several Asian ethnic subgroups, insufficient disaggregated data are available for many of the Asian ethnic groups that comprise this very heterogeneous population.

Pre-Operative Recommendations

The 2019 Clinical practice guideline developed by AACE, ACE, The Obesity Society, ASMBS, Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) addresses the nonsurgical support of those who will be undergoing bariatric procedures (Mechanick, 2019). The societies recommend that the initial history and physical (H&P) include a weight loss history as well an evaluation of commitment. Formal domains for preoperative psychosocial evaluation are weight history, eating-disorder symptoms (e.g., night-eating syndrome, binge eating, compensatory behaviors, anorexia nervosa), psychosocial history, developmental and family history, current and past mental health treatment, cognitive functioning, personality traits and temperament, current stressors, social support, quality of life, health-related behaviors (substance abuse, smoking history, adherence, and physical activity), motivation and knowledge base (including weight loss expectations), and self-harm and suicide. 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. Preoperative weight loss may lead to a less complex surgical procedure and improved postoperative outcomes. This has been theorized to be due to improvements in the vascular or respiratory system or improved technical aspects, such as reduced liver volume (Carter, 2021; Mechanick, 2019; Sun, 2020). However, any delays might be at the expense of further aggravating obesity replated conditions. Pre-procedure weight loss may be recommended in selected cases to improve co-morbidities in some individuals but is not recommended as a standard measure.

Evolving Guidelines

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. The evidence cited by the guideline to support recommending surgery in individuals with BMIs of 30 kg/m2 to <35 kg/m2 or expanding recommendations in those with a BMI of ≥ 35 kg/m2 without comorbidities is limited. The size of the trial arms includes 50 or less participants in most cases, with inclusion criteria being non-specific to the target population. Considerable heterogeneity exists between cited studies, with inconsistent results reported.

Bariatric Surgery and Type 2 Diabetes

Resolution (cure) or improvement of type 2 diabetes mellitus after bariatric surgery and observations that glycemic control may improve immediately after surgery, before a significant amount of weight is lost, have promoted interest in a surgical approach to treatment of type 2 diabetes. The various surgical procedures have different effects, and gastrointestinal rearrangement seems to confer additional anti-diabetic benefits independent of weight loss and caloric restriction. The precise mechanisms are not clear, and multiple mechanisms may be involved. Gastrointestinal peptides, glucagon-like peptide-1 (1GLP-1), glucose -dependent insulinotropic peptide (GIP), and peptide YY (PYY) are secreted in response to contact with unabsorbed nutrients and by vagally mediated parasympathetic neural mechanisms. GLP-1 is secreted by the L cells of the distal ileum in response to ingested nutrients and acts on pancreatic islets to augment glucose-dependent insulin secretion. It also slows gastric emptying, which delays digestion, blunts postprandial glycemia, and acts on the central nervous system to induce satiety and decrease food intake. Other effects may improve insulin sensitivity. GIP acts on pancreatic islets to augment glucose-dependent insulin secretion It also slows gastric emptying, which delays digestion, blunts postprandial glycemia, and acts on the central nervous system to induce satiety and decrease food intake. Other effects may improve insulin sensitivity. Glucose-dependent insulinotropic peptide acts on pancreatic beta cells to increase insulin secretion through the same mechanisms as glucagon-like peptide-1, although it is less potent.

In a cited joint statement by international diabetes organizations (Brito, 2017), the authors noted that a firm link between the use of metabolic surgery to control diabetes and to prevent diabetic complications has not yet been established. Bariatric surgery is effective for patients with T2D but is invasive and has risks, and its effects often wane over time. The consensus guideline recommends considering surgery for patients with T2D, particularly those with severe obesity, and advances the field by providing guidance for preoperative evaluation and postoperative follow-up.

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What is Not Considered Medically Necessary?

BCBS has specific instances when bariatric procedures are not considered medically necessary. These include:

• 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.
• Initial and reoperative bariatric procedures are considered not medically necessary when the criteria listed above are not met.
• 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.
• Endoscopically placed percutaneous aspiration tube (such as AspireAssist®).
• When services are Not Medically Necessary: For the procedure codes listed above when criteria are not met, when the following BMI diagnosis codes are indicated, or when the code describes a procedure or situation designated in the Clinical Indications section as not medically necessary.

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.
• There is documentation of a complication related to the initial procedure (including but not limited to, obstruction, stricture or documented GERD).
• * Revision/ conversion indications apply to the procedures listed under criteria B for the initial procedure.
• Conversion: A second bariatric procedure that changes the bariatric approach from the index procedure to a different type of procedure (e.g., sleeve gastrectomy or adjustable gastric band converted to RYGB.
• Revision: A procedure that corrects or modifies anatomy of a previous bariatric procedure to improve the intended outcome or correct a complication.

Additional Weight Loss Options Covered by BCBS

• In addition to good nutrition and physical activity, many FDA-approved weight-loss medications can help reduce weight by at least 5%. We cover weight-loss drug prescriptions to treat obesity for Service Benefit Plan members who meet eligibility criteria and get prior approval. FEP also covers procedures to treat morbid obesity. Note: Prior approval is required for surgery for morbid obesity.
• With the Weight Management Program by Livongo®, eligible members can get a digital scale and ongoing support to manage their weight and improve their health. This program is available to all members 13 and older. To participate, you 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.
• FEP Blue Focus® members can get rewarded for having their annual physical every year.
• Connect with a registered dietician who can evaluate your nutritional needs and help you develop personalized meal plans-all from your phone or computer.
• 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.
• With Blue365®, you can achieve your personal fitness goals on your budget.

Blue Distinction Centers

Blue Cross and Blue Shield designates certain facilities as Blue Distinction Centers and Blue Distinction Centers+ for bariatric surgery. These centers provide a full range of bariatric surgery care, including surgical care, post-operative care, outpatient follow-up care, and patient education. Blue Distinction Centers (BDC) met overall quality measures for patient safety and outcomes, developed with input from the medical community. Blue Distinction Centers+ (BDC+) also met cost measures that address consumers’ need for affordable health care.

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