Insurance Claim Form and Glasses Full view

BCBS of Illinois – Requirements For Weight Loss Surgery

BCBS Illinois covers weight loss surgery. However, to qualify for coverage of weight loss surgery, your policy must include coverage. As not all policies include coverage, please talk directly to BCBS Illinois to find out if you policy includes coverage.

BCBS Illinois Pre-Approval Requirements

The benefit plan of the patient should explicitly include weight loss surgery. The contract is the final word when deciding if a patient is eligible for bariatric surgery. If your plan includes coverage, then coverage is provided to patients considered to be morbidly obese. The pre-approval requirements for bariatric surgery include:

  • Patient is over the age of 18 at the time of the surgery.
  • Patient should have Body Mass Index of over 40 or over 35 if they suffer from at least two of the following weight-related illnesses:
    • Coronary heart disease
    • Sleep apnea
    • Diabetes mellitus
    • Hypertension
    • Osteoarthritis
    • Dyslipidemia

The patient should have undergone treatment for the conditions listed above without the desired results. This is typically evidenced by medical records from your primary care physician. And you may need your primary care physician to provide a letter of medical necessity.

  • The surgeon has to attest that the patient has been briefed about the surgery and the diet and lifestyle changes needed to be taken up after the surgery. Documentation is required for the same. The regimen will outline:
    • Changes in behavior.
    • A change in the nutritional plan to focus on low-fat and calorie intake.
    • Increase in volume of physical activity.
    • Lifestyle support.
  • The patient has to undergo evaluation by a licensed medical practitioner within 12 months before the surgery.
  • The patient can be evaluated by a psychologist, professional counselor or psychiatrist to:
    • Determine that the patient has the mental ability to understand the procedure.
    • Ensure that no psychological health issues will clash with the results of the bariatric procedure.
    • Assess the patient’s willingness and cooperation to follow the regimen after the procedure

Patients who don’t get a clean bill of mental health are not covered by the plan.

Types of Weight Loss Surgeries Covered by BCBS Illinois

The BCBS Illinois plan provides coverage for the following types of weight loss surgeries:

All these procedures are considered medically necessary and covered by insurance.

Procedures Excluded from Coverage

The procedures excluded from coverage under a BCBS Illinois plan are:

  • Vertical Banded Gastroplasty
  • Biliopancreatic Bypass with Duodenal Switch

These procedures are not considered medically necessary. Any other procedures that are investigational, experimental or unproven are not covered by the health plan.

Is A Second Weight Loss Surgery Covered If Lap Band Doesn’t Work?

Coverage is provided for a second weight loss surgery if lap band doesn’t work. For this, the patient is required to prove that he/she complied with the standard of care and regimen recommended under the weight loss surgery plan. Failure to do so will revoke coverage.

Revisions

A repeat or revision of a bariatric surgery performed on a patient is covered if considered medically necessary. The criteria for coverage include:

  • Patient’s plan covers the original procedure and the revision.
  • Patient followed the post-operative nutrition and exercise plan.
  • Patient meets the BMI criteria for the procedure.
  • Surgery is the only way to address the complications or technical failure of the bariatric procedure.
  • Patient wants a reinstitution of a surgery modality

Does BCBS Illinois Require A Center of Excellence?

The BCBS Illinois plan requires a Center of Excellence.

Do I Have To Use An In-Network Bariatric Surgeon?

You can choose a surgeon from any of the providers that are part of the vast BCBS Illinois network. You may be able to use an out-of-network surgeon to perform your surgery but your out-of-pocket expenses may be higher.

BCBS Illinois’ Contact Info to Inquire About Surgery

To contact BCBS Illinois about weight loss surgery, you can call directly by dialing the number on the back of your insurance card. Or access their online site to find the appropriate phone number.

The 5 Habits Of Weight Loss Surgery Success