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

Your Blue Cross Blue Shield of Vermont 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 Vermont 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 Vermont for bariatric surgery in the United States, you must meet the following criteria:

  1. Be age 18 or older
  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. To determine whether or not patients have responded to conservative measures for weight reduction, patients must have been active participants in non-surgical weight reduction programs that include frequent, e.g., monthly, documentation of weight, dietary regimen, and exercise. In general, patients must have participated in these programs for at least 6 months. These conservative attempts must be reviewed by the practitioner seeking approval for the surgical procedure.
  5. The patient has participated in at least one medically supervised attempt to lose weight within the 2 years preceding surgery. The medically supervised weight loss attempt(s) must include at least six monthly medical visits over six consecutive months with all visits under the direction of a medical doctor physicians’ assistant nurse practitioner or a registered dietitian supervised by an MD, DO, PA, or NP. The patient’s participation in a structured weight loss regimen must be documented in the medical record by an attending practitioner who supervised the patient’s progress. A physician’s notation alone is not sufficient documentation. Documentation should include medical records indicating the patient’s adherence to the current nutrition and exercise program throughout the course of the medically supervised weight loss regimen.
  6. The patient must be evaluated preoperative by a licensed mental health provider (i.e. psychiatrist, licensed psychologist [PhD or MA] or licensed clinical social worker [LICSW]) to ensure the patient’s ability to understand, tolerate and comply with all phases of care and to ensure a commitment to long term follow-up requirements. The evaluation must document that any psychiatric, chemical dependency, or eating disorder contraindication to surgery have been ruled out.
  7. The patient must have undergone an appropriate medical work up which may include upper gastrointestinal series, endoscopy, appropriate preoperative laboratory studies and EKG. A complete physical examination by the attending surgeon and an assessment of thyroid levels is required. If co-morbid conditions (i.e. diabetes or cardiovascular disease) are present, an appropriate evaluation of those conditions is required to ensure that patient is capable of undergoing the procedure.

Revision Requirements

Revision surgery to address perioperative or late complications of a bariatric procedure is considered medically necessary. These include, but are not limited to, staple-line failure, obstruction, stricture, and non-absorption resulting in hypoglycemia or malnutrition, weight loss of 20% or more below ideal body weight.

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 of Vermont 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 Vermont 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 Vermont 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 Vermont Weight Loss Surgery

Please see below for the procedures Blue Cross Blue Shield of Vermont 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 Vermont:

Procedures That Are NOT Covered

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

Blue Cross Blue Shield of Vermont Weight Loss Surgery

If Blue Cross Blue Shield of Vermont 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 Vermont 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: