Capital Blue Cross Weight Loss Surgery - How to Avoid a Denial

Your Capital BlueCross weight loss surgery insurance coverage depends on several factors, all of which are reviewed below.

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Capital BlueCross 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 Capital BlueCross for bariatric surgery in the United States, you must meet the following criteria:

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

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

    Use this BMI Calculator to check your body mass index…

  4. Patients should have documented failure to respond to conservative measures for weight reduction prior to consideration of bariatric surgery, and these attempts should be reviewed by the practitioner prior to seeking approval for the surgical procedure

Adolecents Requirements

Guidelines for bariatric surgery in adolescents are not uniform, with variability in weight-based criteria, ranging from a BMI of 35 with comorbidities to a BMI of 50. Most guidelines use weight-based criteria that parallel those for adult patients.

In addition to the weight-based criteria, there is greater emphasis on issues of developmental maturity, psychosocial status, and informed consent for adolescent patients. All guidelines mention these issues, but recommendations are not uniform for addressing them.

Revision Requirements

Revision surgery to address perioperative or late complications of a bariatric procedure is considered medically necessary, including:

  • 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 or dilation proximal to an adjustable gastric band 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.

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.

Capital BlueCross 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.

Capital BlueCross does cover weight loss surgery, but your specific policy must include it in order for you get it covered.

Following are a list of Capital BlueCross 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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Capital BlueCross Weight Loss Surgery

Please see below for the procedures Capital BlueCross 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 Capital BlueCross:

Procedures That Are NOT Covered

The following procedures are NOT covered by Capital BlueCross:

Capital BlueCross Weight Loss Surgery

If Capital BlueCross 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 Capital BlueCross 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: