BCBS of North Dakota Weight Loss Surgery - How to Avoid a Denial

Your Blue Cross Blue Shield of North Dakota weight loss surgery insurance coverage depends on several factors, all of which are reviewed below.

To request a free insurance check, click here to contact a top local surgeon. Alternatively, use the tool below to find out if you have coverage.

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Blue Cross Blue Shield of North Dakota Weight Loss Surgery

READ THIS FIRST

Even if your insurance company covers bariatric surgery in some plans, that does not mean that your specific plan covers it. The obesity surgery approval requirements in this section assume that weight loss surgery is covered by your specific policy.

To confirm whether your specific policiy covers bariatric surgery, click here to contact a surgeon and ask for a free insurance check.

Disclaimer: The information contained on this page may not include all components of your insurance company’s medical policy and/or may not be up to date. Contact your insurance company to confirm all benefits.

In order to be approved by Blue Cross Blue Shield of North Dakota for bariatric surgery in the United States, you must meet the following criteria:

  1. Be age 18 years or older
  2. Diagnosis of Morbid obesity, defined as
  3. Or

    • BMI 35 – 39.9 AND one of the following
      • Uncontrolled type 2 diabetes
      • Poorly controlled hypertension
      • Obstructive sleep apnea
      • Severe arthropathy of hips, knees, or lumbar spine
      • Poorly controlled dyslipidemia
      • Idiopathic Intracranial Hypertension (pseudotumor cerebri)

    Use this BMI Calculator to check your body mass index…

  4. There is documentation of 3 months of active participation in a diet and exercise program as recommended by the bariatric surgical multidisciplinary team. The scope and depth of this program is at the discretion of the bariatric surgical multidisciplinary team, and BCBSND does not specify the content of this program. There must be a second visit to the bariatric surgical team at least 3 months after the initial visit, and the subsequent visit must document the member’s active participation and adherence to the surgical team’s prescribed diet and exercise program. This documentation should contain specific data on weight, diet adherence, and exercise program adherence
  5. Has not smoked for at least 3 months prior to surgery
  6. Submission of a formal psychiatric evaluation by a licensed mental health provider who has appropriate working knowledge of the nature and mechanics of bariatric surgical procedures, knowledge of the psychology of eating and morbid obesity, and an understanding of the complexity with which these factors may manifest in the postoperative patient. ALL of the following must be documented by the mental health provider:
    • Absence of current DSM-5 psychiatric disorder (including consideration of personality disorders, intellectual disabilities or neurocognitive disorders) which would hinder successful adherence with post-surgical weight loss regimen.
    • Absence of active substance abuse within the past one yea

Adolecents Requirements

Bariatric surgery in adolescents may be considered medically necessary according to the same weight-based criteria used for adults, but greater consideration should be given to psychosocial and informed consent issues.

Revision Requirements

Revision surgery, meaning, repositioning or removal of a lap-band device, reversal (“takedown”) of a prior restrictive or malabsorptive bariatric surgical procedure, revision of the initial procedure, or conversion from one type of procedure to another (eg, removal of lap-band and performance of sleeve at the same time), may be considered Medically Necessary when criteria the following criteria are met:

  • The initial bariatric surgical procedure was a Covered Service as defined in their Benefit Plan
  • There is adequate and complete clinical documentation in the medical record (e.g. radiologic studies, endoscopic reports, clinic notes) of one or more complications directly and proximately related to the initial bariatric surgical procedure, such as:
    • Slipped lap-band
    • Flipped lap-band port
    • Broken lap-band device
    • Erosion of lap-band
    • Stoma ulcer
    • Stoma dilation
    • Pouch dilation
    • Mechanical obstruction
    • Stricture
    • Non-absorption resulting in documented hypoglycemia or malnutrition
    • Weight-loss of 20% or more below ideal body weight
    • Staple-line failure
    • Leakage
    • Medically refractory gastroesophageal reflux, esophagitis, and/or vomiting, with or without hiatal hernia
    • Infection around any implanted hardware
    • Bleeding
    • Severe dumping
    • Failure of the primary procedure to achieve adequate weight loss, defined as failure to achieve weight loss of at least 25% excess body weight (25% EBW) at least two years out from the original procedure, when the clinical documentation shows that the member has been adhering to the post-bariatric-surgical aftercare plan regarding diet, nutrition, exercise and all required follow-up

If Your Policy Does NOT Cover It: Seek Partial Coverage

You may be able to get part of the costs paid for by insurance even if weight loss surgery isn’t covered. It’s all about how your doctor and hospital submit your claims to your insurance company.

For example, there are many non-bariatric surgery reasons for your doctor to recommend:

  • Cardiology exam
  • Lab work
  • Medically supervised diet program
  • Psychological exam
  • Sleep study

These are ordered for many reasons other than bariatric surgery and may be covered as a result. If your doctor submits one of these claims using a weight loss surgery CPT code (Current Procedural Terminology Code), your insurance is unlikely to cover it. But if your doctor uses a general CPT code, it probably will be covered.

While this may sound “sneaky”, it is an ethical practice. After all, these tests will be beneficial regardless of whether you move forward with surgery.

Blue Cross Blue Shield of North Dakota Weight Loss Surgery

Before getting into the types of insurance plans, you can cut to the chase by contacting a local bariatric surgeon’s office. Most surgeons will contact your insurance company for free to confirm whether or not you’re covered.

Click here to find a local surgeon and ask them to check your insurance for you for free.

Blue Cross Blue Shield of North Dakota does cover weight loss surgery, but your specific policy must include it in order for you get it covered.

Following are a list of Blue Cross Blue Shield of North Dakota plan types and whether they cover bariatric surgery:

Weight Loss Surgery for Health Plans Through Your Work

If you work for a company that has 50 or more full time employees, it is completely up to your employer to decide whether or not to cover bariatric surgery under your health plan.

To find out whether weight loss surgery is covered by your employer’s plan, you have a few options:

Weight Loss Surgery for Individual/Family Plans

The Affordable Care Act (Obamacare) requires all individual and small group plans (less than 50 full time employees) to include weight loss surgery coverage as long as it is considered an “Essential Health Benefit” in your state.

The following states DO currently consider bariatric surgery an Essential Health Benefit (bariatric surgery is covered by all individual, family and small group plans in these states):

Your State Not on the List?

If your state is NOT on the list, then weight loss surgery is probably NOT covered under your plan.

First, contact your local surgeon to be sure. For no charge, their office will contact your insurance company on your behalf to work through the details.

If your surgeon confirms that your policy does not include obesity surgery, you still have several options for making surgery more affordable. See these pages for more information:

    • Arizona
    • California
    • Delaware
    • Hawaii
    • Illinois
    • Iowa
    • Maine
    • Maryland
    • Massachusetts
    • Michigan
    • Nevada
    • New Hampshire
    • New Jersey
    • New Mexico
    • New York
    • North Carolina
    • North Dakota
    • Oklahoma
    • Rhode Island
    • South Dakota
    • Vermont
    • West Virginia
    • Wyoming

Regardless of whether your state is on the list, contact a qualified surgeon to request a free insurance check to verify your coverage.

To review your insurance company’s obesity surgery coverage requirements, click here to jump back up the page.

Weight Loss Surgery for Medicare Plans

All Medicare plans are required to cover the following weight loss surgery procedures:

However, special Medicare-specific criteria apply. Click here to learn more about Medicare bariatric surgery coverage.

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Blue Cross Blue Shield of North Dakota Weight Loss Surgery

Please see below for the procedures Blue Cross Blue Shield of North Dakota covers, might cover under certain circumstances, and those that are not covered under any circumstances:

Procedures That ARE Covered

Procedures That MIGHT BE Covered

The following procedures MIGHT BE covered by Blue Cross Blue Shield of North Dakota:

Procedures That Are NOT Covered

The following procedures are NOT covered by Blue Cross Blue Shield of North Dakota:

Blue Cross Blue Shield of North Dakota Weight Loss Surgery

If Blue Cross Blue Shield of North Dakota denies your weight loss surgery claim and you think it should be covered, consider filing an appeal.

Our Health Insurance Appeals page will get you started, then head over to the Disputes & Appeals page for Blue Cross Blue Shield of North Dakota to learn how to proceed.

Search the weight loss surgeon directory below to ask a top surgeon about a free insurance check by country and region: