Blue cross blue shield federal bariatric surgery requirements 2022

Bariatric and Transplant care benefits are limited to services provided in a Blue Distinction Center (see pages 62 and 66). If you are considering covered cardiac procedures, cancer care, knee or hip replacement, or spine surgery, you may want to consider receiving those services at a Blue Distinction Center. To locate a Blue Distinction Center, visit www.fepblue.org/provider to use our National Doctor & Hospital Finder, or call us at the customer service telephone number listed on the back of your FEP Blue Focus ID card.

Table of Contents Show

Requirements for Pre-Approval of Weight Loss Surgery with Blue Cross
What Weight Loss Procedures Does Blue Cross Cover?
Procedures Blue Cross Does Not Cover
Other Considerations
Does Fepblue cover weight loss programs?
Which criteria qualifies a patient for bariatric surgery?
Can you get denied for weight loss surgery?
What BMI qualifies and individual for bariatric surgery?

Benefits for bariatric surgery are limited to the procedures below and must be performed in a Blue Distinction® Specialty Care Center for Bariatric (weight loss) surgery and must meet the requirements indicated on pages 62-63.

Roux-en-Y
Gastric bypass
Laparoscopic adjustable gastric banding
Sleeve gastrectomy
Biliopancreatic bypass with duodenal switch

Blue Distinction Centers for Transplants®

Blue Distinction Centers for Transplants are selected based on their ability to meet defined clinical quality criteria that are unique for each type of transplant. For more information see page 66.

The following transplants must be performed at a Blue Distinction Centers for Transplants:

Heart (adult and pediatric)
Liver (adult and pediatric liver alone; adult only for simultaneous liver-kidney)
Pancreas; pancreas transplant alone; pancreas after kidney; simultaneous pancreas-kidney (adult only)
Single, double, or lobar lung transplant (adult only)
Blood or marrow stem cell transplants (adult and pediatric), see pages 67-69
Transplant services related to the above listed transplants, see page 71

For more information or to locate a Blue Distinction Center, visit www.fepblue.org/provider to use our National Doctor & Hospital Finder, or call us at the customer service telephone number listed on the back of your FEP Blue Focus ID card.

What you must do to get covered care

You must use Preferred providers in order to receive benefits, except under the situations listed below. In addition, we must approve certain types of care in advance. Please refer to Section 4, Your Costs for Covered Services, for related benefits information.

Exceptions:

Medical emergency or accidental injury care in a hospital emergency room and related ambulance transport as described in Section 5(d), Emergency Services/Accidents;
Professional care provided at Preferred facilities by Non-preferred radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, emergency room physicians, and assistant surgeons;
Laboratory and pathology services, X-rays, and diagnostic tests billed by Non-preferred laboratories, radiologists, and outpatient facilities;
Services of assistant surgeons;
Care received outside the United States, Puerto Rico, and the U.S. Virgin Islands; or
Special provider access situations, other than those described above. We encourage you to contact your Local Plan for more information in these types of situations before you receive services from a Non-preferred provider.

The average weight of Americans has doubled in the past 30 years, according to the CDC. Weight loss surgery is considered an effective treatment of morbid obesity. While most of the Blue Cross insurance policies do cover weight loss surgery, not all of them do. Those that do cover the procedure have similar requirements to those of Blue Cross Blue Shield (BCBS) of Michigan. It is important that you meet these criteria in order to benefit from the insurance company’s coverage for the entire process.

Requirements for Pre-Approval of Weight Loss Surgery with Blue Cross

Your Anthem Blue Cross insurance policy covers weight loss surgery unless it states specifically that it excludes it. In order to be pre-approved for the procedure you must meet the following requirements:

You need must be between the ages of 18 and 60 years old
Exceptions to the age requirement can be made for patients under 18 years old if a letter is provided to the carrier by the physician stating that there is a dramatic risk for the patient’s health if surgery is withheld. Additionally, the letter should contain information regarding the physician’s evaluation of the patient’s mental health and have determined that the patient is prepared for such a surgery
You need to be at a documented BMI level of over 40, or
You need to be at a documented BMI level of over 35 and suffer from a minimum of one comorbid condition such as:
- Hypertension,
- Obstructive sleep apnea,
- Impaired glucose tolerance,
- Type 2 diabetes,
- Coronary artery disease.
Written evidence must show that other weight loss programs have failed to help the patient reduce or control their weight. These other programs must have been utilized for a minimum of twelve months consecutively to be considered. Some of these programs should have been prescribed by a physician other than the weight loss surgeon and may include:
- Weight Watchers
- Jenny Craig
- Top weight loss diet plans
- Any medically supervised weight loss programs.

What Weight Loss Procedures Does Blue Cross Cover?

The weight loss procedures that Blue Cross covers include.

Lap Adjustable Gastric Bands
Vertical Banded Gastroplasty
Duodenal Switch
Biliopancreatic Bypass
Gastric Sleeve Procedure
Gastric Bypass

Procedures Blue Cross Does Not Cover

While Blue Cross does cover most of the weight loss procedures there are a few that they do not. These include:

Open and Laparoscopic Sleeve Gastrectomy
Open Adjustable Gastric Banding
Laparoscopic and open vertical banded Gastrectomy

Other Considerations

While you go into the weight loss surgery with high hopes and expectations that it will be a success, there is always a possibility that it will not be as successful as you had hoped. If this is the case and you find a second surgery or procedure is needed, you might find that Blue Cross Blue Shield does provide coverage for a second surgery as long as you followed post-operative instructions and made lifestyle changes for success as well as turned to the bariatric surgeon and other sources for additional help. Blue Cross Blue Shield does cover a revision surgery if it is needed. They do require that certain documentation is provided by the physician including:

Reasons for failure of the surgery
Date and type of procedure
Evidence of patient’s compliance with all post-operative instructions including diet and exercise regimens

Blue Cross Blue Shield does not require that you seek surgery with an in-network surgeon. They do recommend that you utilize their in-network surgeons, however, in order to take advantage of their Center of Excellence. You can obtain a list of these professionals from your Blue Cross Blue Shield agent if you would like to consider these individuals for your surgery. Make sure that the individual that you do choose to work with is able to submit directly to Blue Cross Blue Shield for coverage of your procedure.

Related Resources

How to Appeal Insurance Denial for Weight Loss Surgery
What Bariatric Surgeries Are Covered By Insurance?

Does Fepblue cover weight loss programs?

Medical and pharmacy updates We will cover approved weight-loss drugs through the Pharmacy Program to support members who are obese. You must receive prior approval for this benefit.

Which criteria qualifies a patient for bariatric surgery?

To be eligible for weight-loss surgery, you must meet the following requirements: Have a body mass index (BMI) of 40 or higher, or have a BMI between 35 and 40 and an obesity-related condition, such as heart disease, diabetes, high blood pressure or severe sleep apnea.

Can you get denied for weight loss surgery?

Background: Many patients who seek weight loss surgery are denied an operation because of insurance barriers, psychological concerns, and poor medical fitness for surgery.

What BMI qualifies and individual for bariatric surgery?

Weight-loss surgery might be an option for an adult with a BMI of 40 or higher. The surgery may also be an option for an adult who meets these three conditions: BMI of 35 or higher. At least one obesity-related medical condition.

blue cross blue shield federal bariatric surgery requirements