BCBS of Kansas City Weight Loss Surgery - How to Avoid a Denial

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

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Blue Cross Blue Shield Kansas City 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 policy 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 Kansas City for bariatric surgery in the United States, you must meet the following criteria:

  1. Growth is completed (generally, growth is considered completed by 18 years of age)
  2. Diagnosis of Morbid obesity, defined as
  3. Or

    • BMI 35 – 39.9 AND one of the following
      • Diabetes mellitus
      • Obstructive sleep apnea
      • Coronary artery disease
      • Hypertension

    Use this BMI Calculator to check your body mass index…

  4. Completion of the following:
    • Physician records for the 12 months immediately preceding the request for bariatric surgery must be submitted. A physician’s summary letter is not sufficient documentation. The documentation should include the physician’s initial assessment, and subsequent assessment of progress at each visit documenting:
      • The member’s participation in a physician-supervised nutrition and exercise program that includes dietician consultation, low calorie diet, increased physical activity, and behavioral modification for a total of at least 6 consecutive months within the 12 months prior to consideration for surgery
      • Weight loss attempts (diet, exercise, medication, etc.) including the length of time for each method at the weight loss attained
      • Medical records of the attending physician, which document the patient’s weight and progress at each visit, will be required for review
      • Co-morbid conditions including treatment for those conditions
    • The member must have attempted weight loss in the past without successful long-term weight reduction
    • For members participating in a physician-administered nutrition and exercise program (e.g. OptiFast, MediFast), program records that document participation and progress, may substitute for the physician’s medical records
  5. If the member has been pregnant, she must be at least 12 months post-partum from the date of receipt of the application for the surgery
  6. The Blue KC Bariatric Surgery Questionnaire (included at the end of this policy) must be completed, with all required attachments, and submitted for review
  7. After qualifying for surgery based on the guidelines above, and for three months immediately prior to the surgery, the member must participate in a physician directed organized multidisciplinary surgical preparatory regimen meeting all of the following criteria in order to improve surgical outcomes, reduce the potential for surgical complications and establish the member’s ability to comply with post-operative medical care and dietary restrictions:
    • Consultation with a dietician or nutritionist
    • Reduced-calorie diet program supervised by dietician or nutritionist
    • Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional

    Important note about physician summary letters

    A physician’s summary letter, without evidence of contemporaneous oversight is not sufficient documentation.

    Documentation should include medical records of the physician’s initial assessment of the member, and the physician’s assessment of the member’s progress at the completion of the multidisciplinary surgical preparatory regimen.

    • Behavior modification program supervised by qualified professional with lifestyle changes documented by all of the following:
      • Loss of 5% of his/her body weight in the 3 months prior to surgery
      • Diet record
    • Documentation in the medical record of the member’s participation in the multidisciplinary surgical preparatory regimen at each visit
  8. Documentation of social support prior to and after the surgery
  9. Documentation indicating the patient is willing to commit to long-term follow up and be compliant with recommendations

Adolescents 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 (see Considerations). In addition, any devices used for bariatric surgery must be in accordance with the FDA-approved indications for use.

Revision Requirements

Revision of a bariatric procedure may be medically necessary if it is addressing perioperative or late complications of the original procedure. These include, but are not limited to:

  • staple-line failure
  • obstruction
  • stricture
  • non-absorption resulting in hypoglycemia or malnutrition
  • weight loss of 20% or more below ideal body weight
  • band slippage that cannot be corrected with manipulation or adjustment

Revision of a primary bariatric procedure that has failed due to dilation of the gastric pouch (documented by upper gastrointestinal examination or endoscopy) is considered medically necessary if the initial procedure was successful in inducing weight loss prior to pouch dilation and the patient has been compliant with a prescribed nutrition and exercise program and the patient still meets criteria (BMI) for bariatric surgery.

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 Kansas City 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 Kansas City 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 Kansas City 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 Kansas City Weight Loss Surgery

Please see below for the procedures Blue Cross Blue Shield Kansas City 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 Kansas City:

Procedures That Are NOT Covered

The following procedures are NOT covered by Blue Cross Blue Shield Kansas City:

  • Gastric Balloon
  • vBloc Therapy
  • AspireAssist
  • Vertical Banded Gastroplasty
  • Mini Gastric Bypass Surgery
  • Biliopancreatic bypass without duodenal switch (CPT 43645, 43847)
  • Long-limb gastric bypass procedure (i.e., >150 cm) (CPT 43847)
  • Two-stage bariatric surgery procedures (e.g., sleeve gastrectomy as initial procedure followed by biliopancreatic diversion at a later time)
  • Endoscopic procedures (e.g., insertion of the StomaphyX™ device) as a primary bariatric procedure or as a revision procedure, (i.e., to treat weight gain after bariatric surgery to remedy large gastric stoma or large gastric pouches)
Blue Cross Blue Shield Kansas City Weight Loss Surgery

If Blue Cross Blue Shield Kansas City 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 Kansas City 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: