BCBS of Alabama Weight Loss Surgery - How to Avoid a Denial

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

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Blue Cross Blue Shield Alabama 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 Alabama for bariatric surgery, you must meet the following criteria:

For Gastric Restrictive Procedures

Restrictive procedures include gastric banding/lap band, gastric bypass, gastric sleeve and vertical banded gastroplasty – see the Covered Procedures section below for links to our specific procedure explanation pages

Policy About Gastric Band Adjustments

If the adjustable gastric restrictive procedure does not meet medical criteria for coverage, or if the patient decides to pay for the adjustable gastric restrictive procedure, the adjustments of the devices do not meet medical criteria for coverage.

  1. BMI of 40 or greater, or BMI of 35 or greater with one or more of the following co-morbid conditions:
    • HTN on optimal drug therapy
    • atherosclerotic cardiovascular disease
    • diabetes (must be treated with insulin or oral agents)
    • pulmonary hypertension
    • severe obstructive sleep apnea (RDI of 50 or greater).
  2. The condition of morbid obesity (BMI of 40 or greater 35 or greater with presence of comorbid conditions) must be of at least 3 years duration.
    • There must be documentation in medical records by a primary care or attending physician of patient height and weight for the past 3 years. A letter from the primary care physician and dated photographs will be considered in lieu of recorded heights and weights. Random reviews of these patients’ charts for accuracy of stated information will be conducted.
  3. Use this BMI Calculator to check your body mass index…

  4. Documentation must be present of participation in medically supervised weight loss program.
    • For purposes of coverage, we (BCBS) recognize medical supervision of the diet and activity program by practicing MD’s who are not bariatric surgeons, such as family practitioners, internists, and other primary care specialties (medically supervised weight loss or activity programs generally are not a covered benefit).
    • Documentation provided by these health care providers will be recognized in the review process. At least one attempt must occur during the one year prior to request for surgery or date of surgery. Documentation must support participation in the program for six consecutive months.
    • The following criteria must be met for this participation:
      • Documentation of participation in a physician supervised program of nutrition and increased physical activity (including dietitian consultation, low calorie diet, increased physical activity and behavioral modification). Documentation of program participation must appear in the medical record no less than monthly for a period of 6 consecutive months by the attending physician. Documentation should include comments by the physician regarding patient progress or lack of progress. A letter does not meet this requirement. There must be medical records to document medically supervised weight loss attempts
      • Medical record documentation of a 6 consecutive month, nutrition-led weight loss program (Weight Watchers, LA Weight Loss, Jenny Craig, EatRight, etc.) with a minimum of 3 physician visits during that 6 month period documenting medical supervision, Not acceptable are self-directedprograms such as joining a gym, Atkins’ diet, calorie counting, low fat,cutting back, internet programs, etc.
  5. A complete history and physical must be performed by the bariatric surgeon to include height and weight.
  6. The patient must be at least 18 years of age.
  7. Due to the surgical morbidity associated with concomitant pulmonary disease coverage will not be provided for anyone who has smoked in less than eight weeks prior to surgery.

For Malabsorptive Procedures (Duodenal Switch Surgery)

Open or laparoscopic biliopancreatic bypass (i.e., the Scopinaro) procedure with duodenal switch meets Blue Cross and Blue Shield of Alabama’s medical criteria for coverage fortreatment of the morbidly obese patients with BMI of 50 or more when the following criteria are met:

  1. Documentation must be present of participation in medically supervised weight loss program.
    • For purposes of coverage, we (BCBS) recognize medical supervision of the diet and activity program by practicing MD’s who are not bariatric surgeons, such as family practitioners, internists, and other primary care specialties. Documentation provided by these health care providers will be recognized in the review process.
    • At least one attempt must occur during the one year prior to request for surgery or date of surgery. Documentation must support participation in the program for six consecutive months. The following criteria must be met for this participation:
      • Documentation of participation in a physician supervised program of nutrition and increased physical activity (including dietitian consultation, low calorie diet, increased physical activity and behavioral modification). Documentation of program participation must appear in the medical record by the attending physician. Documentation should include comments by the physician regarding patient progress or lack of progress. A letter does not meet this requirement. There must be medical records to document medically supervised weight loss attempts
      • Acceptable with medical record documentation of medical supervision are: Weight Watchers, LA Weight Loss, Jenny Craig, EatRight etc. Not acceptable are self-directed programs such as joining a gym, Atkins’ diet, calorie counting, low fat, cutting back, internet programs, etc.
  2. A complete history and physical must be performed by the bariatric surgeon to include height and weight.
  3. The patient must be at least 18 years of age.
  4. Due to the surgical morbidity associated with concomitant pulmonary disease coverage will not be provided for anyone who has smoked in less than eight weeks prior to surgery

See our Duodenal Switch page for more information about this procedure.

Revision Requirements

Gastric Surgery Revision

Revision of a prior bariatric procedure (excluding adjustable gastric banding) meets Blue Cross and Blue Shield of Alabama’s medical criteria for coverage with documented evidence of one or more of the following:

    • Weight loss of 20% or more below the ideal body weight following bariatric surgery,
    • Vomiting (bilious)
    • Stomal dilatation documented by either upper gastrointestinal (UGI) series or esophagogastroduodenoscopy (EGD)
    • Pouch dilatation documented by either upper gastrointestinal (UGI) series or esophagogastroduodenoscopy (EGD)
    • Stomal stenosis after vertical gastric banding, documented by endoscopy, with vomiting or weight loss of 20% or more below the ideal body weight
    • Staple line failure, documented by either upper gastrointestinal (UGI) series or esophagogastroduodenoscopy (EGD)
    • Severe diarrhea following surgery
    • Severe dumping syndrome

The requested procedure must be a Blue Cross and Blue Shield of Alabama covered bariatric surgery/procedure

Complications Due to Non-Compliance

Complications (e.g., stomal dilatation, pouch dilatation, or staple line failure) that arise due to non-compliance with medical recommendations such as dietary restrictions, patient activityand/or lifestyle following the procedure do not meet Blue Cross and Blue Shield of Alabama’s medical criteria for coverage.

Gastric Surgery Revision

Revision or removal of adjustable gastric restrictive device meets Blue Cross and BlueShield of Alabama’s medical criteria for coverage for the following indications:

    • Band erosion or slippage
    • Infections around the port site

Elective removal of the adjustable gastric restrictive device does not meet Blue Cross andblue Shield of Alabama’s medical criteria for coverage.

Repeat surgery for morbid obesity for other than the stated surgical complications does not meet Blue Cross and Blue Shield of Alabama’s criteria for coverage.

Please verify contract benefits for coverage of bariatric surgery and complications.

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.

Contact Blue Cross Blue Shield Alabama to Ask About Bariatric Surgery

Blue Cross Blue Shield Alabama 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 Alabama 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 Alabama 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 Alabama Weight Loss Surgery

Please see below for the procedures Blue Cross Blue Shield Alabama 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 Alabama:

Procedures That Are NOT Covered

The following procedures are NOT covered by Blue Cross Blue Shield Alabama:

  • Gastric Balloon
  • vBloc Therapy
  • AspireAssist
  • Mini Gastric Bypass Surgery
  • Bariatric surgery performed as a cure for type 2 diabetes
  • Biliopancreatic Bypass without Duodenal Switch
  • Endoscopic Procedures for weight gain or to remedy large gastric stoma or large gastric pouches after bariatric surgery (e.g. StomaphyX™, ROSE procedure)
  • Fobi-Pouch (FPOO) Transected Vertical Banded Gastric Bypass (Silastic Ring Vertical Gastric Bypass)
  • Gastric Wrapping
  • Jejunoileal Bypass
  • Long Limb Gastric Bypass
  • Loop Gastric Bypass
  • Bariatric surgery revisions due to complications (e.g., stomal dilatation, pouch dilatation, or staple line failure) that arise due to non-compliance with medical recommendation such as dietary restrictions, patient activity and/or lifestyle following the initial procedure.
Blue Cross Blue Shield Alabama Weight Loss Surgery

If Blue Cross Blue Shield Alabama 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 Alabama 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: