BCBS Arkansas – Weight Loss Surgery Requirements

• Requirements
• Procedures Covered
• Center Of Excellence Requirement
• In-Network Provider
• Contact
• Full Policy

It is important to know that your employer can typically opt-out of weight loss surgery insurance coverage for their employees policies. This typically saves the company money on their premiums. So its best to contact BCBS Arkansas directly to ask if your policy covers weight loss surgery.

Even if your policy specifically 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.

BCBS Arkansas Pre-Approval Requirements

Below are the minimum requirements if you are over 20 years of age.

• Body Mass Index (BMI) of 40 or greater OR…
• BMI 36 – 39 with a high-risk co-morbid condition such as uncontrolled diabetes mellitus, uncontrolled obstructive sleep apnea, uncontrolled hypertension or uncontrolled hyperlipidemia
• Have failed a structured weight loss program
• Are well motivated and understand the risks of the surgery and the restricted eating habits which follow surgery

Below are the minimum requirements if you are between 13 and 19 years of age.

• BMI of 40 or greater with serious comorbidities such as type 2 diabetes mellitus, obstructive sleep apnea, pseudo tumor cerebri
• BMI of 50 or more with less severe co morbidities such as hypertension, dyslipidemia, gastroesophageal reflux
• Unsuccessful physician supervised weight loss attempt for at least 6 months
• Achieved 95% or more of his/her adult height by determination of bone age testing
• Psychological assessment to determine decision-making capacity, ability to give informed consent, and willingness to adhere to requirements of post-operative care

If you have not yet begun gathering your medical history we suggest using this excellent tool from Google Health to manage your health history.

Types of Weight Loss Surgeries Covered By BCBS Arkansas

BCBS Arkansas covers the primary weight loss surgeries. These include laparoscopic gastric bypass, Lap Band, and gastric sleeve surgery in some cases.

Covered Weight Loss Surgery Procedures

• Laparoscopic Gastric Bypass
• Vertical Banded Gastroplasty
• Open Gastric Bypass Surgery
• Gastric Banding – including the Lap Band and Realize Band
• Gastric Sleeves – for the super morbidly obese (BMI greater than 60), with severe cardiac or pulmonary comorbidities, that would preclude other surgical procedures for the treatment of morbid obesity (gastric bypass). Gastric sleeve surgery in any other circumstances does not meet member certificate of benefit Primary Coverage Criteria for effectiveness. The procedure is still considered experimental due to a lack of long-term data.

Lap Band Fills Covered?

BCBS Arkansas 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

• Small bowel bypass procedures as stand-alone procedures
• Gastric wrapping
• The Garren-Edwards gastric bubble or any similar device
• Mini gastric bypass

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 in adequate weight loss, such as a lap band or realize band to a gastric bypass, gastric sleeve or duodenal switch may be 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

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, anastamosis leakage and others.

Does BCBS Arkansas Require Center Of Excellence?

Yes, weight loss surgery must be done at a 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.

BCBS Arkansas Contact Info to Inquire About Surgery

BCBS Arkansas contact information is listed by type of policy.

BCBS Arkansas Weight Loss Surgery Full Coverage Statement

BCBS Arkansas’ full policy‘ on weight loss surgery insurance coverage from their web site.