BCBS of Texas – Criteria for Weight Loss Surgery Coverage
Blue Cross Blue Shield of Texas (BCBSTX) covers weight loss surgery. However, some policies do specifically exclude weight loss surgery. Use the contact information at the bottom of this page to find out if your policy has a specific exclusion for weight loss surgery.
Blue Cross Blue Shield of Texas’ Criteria for Insurance Coverage
Two criteria must be met in order to qualify for BCBSTX to cover your procedure.
1. Diagnosis of morbid obesity
- Body Mass Index equal to or greater than 40.
- Body Mass Index equal to or greater than 35 with at least two of the following comorbidities.
- Hypertension, or
- Dyslipidemia, or
- Type 2 Diabetes, or
- Sleep Apnea, or
- Osteoarthritis, AND
2. Documentation from the requesting surgeon that:
- You are at least 18 years of age and fully grown.
- Documentation attesting that you understand the post-operative regimen.
- Evaluation from a professional counselor, psychologist, or psychiatrist within 12 months prior to surgery.
If any of the following apply, you will NOT be eligible for weight loss surgery.
- Patients with mental handicaps that render them unable to understand the rules of eating and exercising post-operatively.
- Patients with portal hypertenstion causing high risk surgery.
- Women who are pregnant or lactating.
- Patients with serious medical illnesses in whom caloric restriction could make the illness worse.
Which Weight Loss Surgeries Are Covered?
- Gastric bypass
- Gastric banding (Lap Band and Realize Band)
- Sleeve gastrectomy
- Biliopancreatic bypass with duodenal switch – only in patients with a BMI over 50.
Unsure which procedure is right for you? Take our test.
Are lap band fills covered?
Yes, lap band fills are covered and its not necessary to request documentation for refill and maintenance procedures.
Which procedures are not covered by BCBSTX?
- Vertical banded gastroplasty
- Long limb gastric bypass procedures
- Mini-gastric bypass
- NOTES or TOGA procedures
Is a second weight loss surgery covered if lap band doesn’t work?
Only if the patient has been compliant with diet and exercise routines post-operatively and had a complication with the original procedure that caused it to fail will BCBSTX pay for a second procedure.
Are revisional surgeries covered?
Revisions are covered when the original procedure does not achieve long term weight loss goals. But the patient must show proof that they have been compliant with the post-operative diet and exercise routines. The surgeon must show that the original gastric pouch dilated or the band slipped or eroded.
Does BCBSTX Require Center of Excellence?
Do I have to use an In-Network Bariatric Surgeon?
You don’t have to but you may save money if you do choose an in-network surgeon and have the procedure at a Blue Distinction Center for Bariatric Surgery.
BCBS of Texas’ Contact Information
BCBS of Texas’ Weight Loss Surgery Full Coverage Statement
The full statement on Bariatric Surgery can be found here.