• Anthem BCBS – Requirements for Weight Loss Surgery

    Posted By on Oct 19, 2013 | 0 comments


    Anthem BCBS does cover weight loss surgery as long as your policy does not specifically exclude coverage. ObesityCoverage strongly feels that morbid obesity is a disease and every insurance company should cover these life saving procedures. So we are happy to report that Anthem BCBS covers weight loss surgery. In fact, most of the Blue cross Blue Shield network has some sort of coverage for weight loss surgery.

    It is important to know that your employer can typically opt-out of weight loss surgery insurance coverage for their employees policies. Opting-out typically saves the company money on their premiums. Contact information for your Anthem BCBS is listed below. Even if your policy excludes weight loss surgery, because BCBS has shown that these types of surgeries are medically necessary you might be able to appeal their exclusion. Before calling make sure you see our questions to ask before calling your insurance company section.

    Note that Blue Cross of California is the trade name for Anthem BCBS so your criteria for weight loss surgery will be the same as it is here.

    Anthem BCBS Pre-Approval Requirements

    The items below are the minimum necessary for approval of your weight loss surgery.

    • Body Mass Index (BMI) of 40 or greater OR…
    • a BMI of 35 or greater with at least 2 comorbidities.
    • Primary Care Physician’s Letter.
    • Active Participation and Documentation of non-surgical methods of weight loss.
    • 18 years of age (special consideration if under 18 with severe morbid obesity and special circumstances).
    • Consult and recommendation from a weight loss surgeon.
    • Psychological evaluation
    • Nutritional evaluation

    Policies Included in Coverage

    • Blue cross Kentucky
    • Blue cross Virginia
    • Blue cross Wisconsin
    • Blue cross Ohio
    • Blue cross California
    • Blue cross Georgia
    • Blue cross Missouri
    • Blue cross New York Empire

    Types of Weight Loss Surgeries Covered By Anthem BCBS

    Recently gastric sleeves have begun to be covered by some of the large insurance companies as a primary weight loss surgery. Currently, gastric sleeves are considered experimental procedures and are not covered.

    Covered Weight Loss Surgery Procedures

    • Laparoscopic Gastric Bypass
    • Open Gastric Bypass Surgery
    • Gastric Banding – including the Lap Band and Realize Band
    • Duodenal Switch also known as Biliopancreatic Diversion
    • Gastric Sleeves

    Unsure which surgery is right for you? Take our bariatric surgery test!

    Lap Band Fills Covered?

    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. Typically, if you paid cash for the procedure ongoing lap band fills will not be covered by insurance.

    Procedures Excluded From Coverage

    • Mini-gastric bypass
    • Banded vertical gastroplasty
    • Any other ‘experimental’ weight loss procedure

    Is a Second Weight Loss Surgery Covered if Gastric Banding Didn’t Work?

    Surgical procedures following a previous weight loss surgery that did not result adequate weight loss, such as a lap band or realize band to a gastric bypass, gastric sleeve or duodenal switch are covered by insurance when the following criteria are met:

    • The patient continues to meet all the medical necessity criteria for bariatric surgery, and
    • There must be documentation that the patient was compliant with the original post-operative dietary and exercise program, and
    • 2 years after the original weight loss surgery, weight loss is still less than 50% of pre-operative excess body weight and weight remains at least 30% of the patients ideal body weight, per BMI.

    Revisions

    • Revisions are covered if there is documentation of a failure secondary to a surgical complication. Complications can include but are not limited to fistula, obstruction or disruption of a suture/staple line.

    Does Anthem BCBS Require Center Of Excellence?

    Do I have to use an in-network weight loss surgeon?

    • No. However, your deductible and out of pocket costs may be significantly lower if you do. And you will still need to find a surgeon that has privileges to perform the surgery at a accredited Center Of Excellence for Bariatric Surgery.

    Anthem BCBS Contact Information

    Anthems can be contacted at 1-866-293-2892. You can also locate a contact number and email address on their website after choosing your state.

    Anthem BCBS Weight Loss Surgery Full Coverage Statement

    Anthem’s full policy on weight loss surgery insurance coverage from their web site.

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