Does blue cross blue shield ppo cover weight loss surgery

Your Empire 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.

TABLE OF CONTENTS

Click on any of the topics below to jump directly to that section

1. Coverage Requirements
2. Coverage Plans
3. Covered Procedures
4. Appealing a Denial
5. Find a Weight Loss Surgeon

SECTION SUMMARY:

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

READ THIS FIRST

Even if your insurance company covers bariatric surgery in some plans, that does not mean that your specific plan covers it. The obesity surgery approval requirements in this section assume that weight loss surgery is covered by your specific policy.

To confirm whether your specific policiy covers bariatric surgery, click here to contact a surgeon and ask for a free insurance check.

Disclaimer: The information contained on this page may not include all components of your insurance company’s medical policy and/or may not be up to date. Contact your insurance company to confirm all benefits.

In order to be approved by Empire Blue Cross Blue Shield for bariatric surgery in the United States, you must meet the following criteria:

1. Be age 18 or older
2. Diagnosis of Morbid obesity, defined as
• a Body Mass Index (BMI) greater than 40

Or

• BMI 35 – 39.9 AND one of the following
• Diabetes mellitus
• Cardiovascular disease
• Hypertension
• Severe obstructive sleep apnea
• Pickwickian syndrome
• Obesity related cardiomyopathy

Use this BMI Calculator to check your body mass index…

3. The individual must have serially documented active participation in a non-surgical weight reduction regimen for at least 6 continuous months, in the 2 years prior to surgery, to enable both behavioral changes and adequate assessment of anticipated postoperative dietary maintenance. These efforts must be fully appraised and documented by the physician requesting authorization for surgery.f
4. The physician requesting authorization for the surgery must provide documentation of ALL of the following:
• The individual’s psychiatric profile is such that the candidate is able to understand, tolerate and comply with all phases of care and is committed to long-term follow-up requirements
• The candidate’s post-operative expectations have been addressed
• The individual has undergone a preoperative medical consultation and is felt to be an acceptable surgical candidate
• The individual has undergone a preoperative mental health assessment and is felt to be an acceptable candidate
• The individual has received a thorough explanation of the risks, benefits, and uncertainties of the procedure
• The candidate’s treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling
• The candidate’s treatment plan includes counseling regarding exercise, psychological issues and the availability of supportive resources when needed

Revision Requirements

Surgical repair 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
• Pouch enlargement due to vomiting

Repeat surgical procedures for revision or conversion to another surgical procedure (that is also considered medically necessary within this document) for inadequate weight loss, are considered medically necessary when ALL the following criteria are met:

• The individual meets ALL the medical necessity criteria for bariatric surgery above.
• 2 years following the original surgery, weight loss is less than 50% of pre-operative excess body weight and weight remains at least 30% over ideal body weight.
• If inadequate weight loss or regain of initial weight loss following the initial surgery is determined to be due to noncompliance with the previously prescribed postoperative dietary and exercise programs, documentation is required to confirm that a mental health assessment has determined that behavioral issues that resulted in inadequate weight loss or regain, related to noncompliance with postoperative dietary and lifestyle modifications following the initial surgery, have been adequately addressed to significantly mitigate the risk of an inadequate weight loss outcome from the additional surgery.

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 isn’t covered. It’s 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
• Lab work
• Medically supervised diet program
• Psychological exam
• Sleep study

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 (Current Procedural Terminology 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.

Empire Blue Cross Blue Shield Contact Information and Full Medical Policy on Bariatric Surgery

• By Phone: 1-866-395-5175
• Contact Empire Blue Cross Blue Shield
• Full Bariatric Surgery Medical Policy for Empire Blue Cross Blue Shield

SECTION SUMMARY:

• Coverage Through Your Employer
• Individual & Family Plans
• Medicare

Before getting into the types of insurance plans, you can cut to the chase by contacting a local bariatric surgeon’s office. Most surgeons will contact your insurance company for free to confirm whether or not you’re covered.

Click here to find a local surgeon and ask them to check your insurance for you for free.

Empire Blue Cross Blue Shield does cover weight loss surgery, but your specific policy must include it in order for you get it covered.

Following are a list of Empire Blue Cross Blue Shield plan types and whether they cover bariatric surgery:

Weight Loss Surgery for Health Plans Through Your Work

If you work for a company that has 50 or more full time employees, it is completely up to your employer to decide whether or not to cover bariatric surgery under your health plan.

To find out whether weight loss surgery is covered by your employer’s plan, you have a few options:

• Your local surgeon will usually be willing check your insurance for free. Click here to find a surgeon near you, then call or email them to request a free insurance review.
• Ask your Human Resources department
• Contact your insurance company directly using the phone number on your insurance ID card

Weight Loss Surgery for Individual/Family Plans

The Affordable Care Act (Obamacare) requires all individual and small group plans (less than 50 full time employees) to include weight loss surgery coverage as long as it is considered an “Essential Health Benefit” in your state.

The following states DO currently consider bariatric surgery an Essential Health Benefit (bariatric surgery is covered by all individual, family and small group plans in these states):

Your State Not on the List?

If your state is NOT on the list, then weight loss surgery is probably NOT covered under your plan.

First, contact your local surgeon to be sure. For no charge, their office will contact your insurance company on your behalf to work through the details.

If your surgeon confirms that your policy does not include obesity surgery, you still have several options for making surgery more affordable. See these pages for more information:

• Weight Loss Surgery Insurance Secrets: Revised List (good tips even if your policy does not include bariatric surgery)
• Financing bariatric surgery (all of your options)

• Arizona
• California
• Delaware
• Hawaii
• Illinois
• Iowa
• Maine
• Maryland
• Massachusetts
• Michigan
• Nevada
• New Hampshire
• New Jersey
• New Mexico
• New York
• North Carolina
• North Dakota
• Oklahoma
• Rhode Island
• South Dakota
• Vermont
• West Virginia
• Wyoming

Regardless of whether your state is on the list, contact a qualified surgeon to request a free insurance check to verify your coverage.

To review your insurance company’s obesity surgery coverage requirements, click here to jump back up the page.

Weight Loss Surgery for Medicare Plans

All Medicare plans are required to cover the following weight loss surgery procedures:

• Gastric sleeve surgery
• Gastric bypass surgery
• Gastric banding (lap band surgery) (LASGB)
• Duodenal switch surgery (DS)
• Biliopancreatic diversion surgery (BPD)

However, special Medicare-specific criteria apply. Click here to learn more about Medicare bariatric surgery coverage.

SECTION SUMMARY:

• General Appeal Instructions
• Appeal Details Specific to Empire Blue Cross Blue Shield

If Empire Blue Cross Blue Shield denies your weight loss surgery claim and you think it should be covered, consider filing an appeal.

Our Health Insurance Appeals page will get you started, then head over to the Disputes & Appeals page for Empire Blue Cross Blue Shield to learn how to proceed.

05.

Find A Top Weight Loss Surgeon

SECTION SUMMARY:

• Ask for a free insurance check or cost quote
• Attend a free seminar or webinar
• Schedule a phone or in-person consultation (both often free)

Search the weight loss surgeon directory below to ask a surgeon about a free insurance check by country and region: