Excellus BCBS Weight Loss Surgery - How to Avoid a Denial

Your Excellus Blue Cross Blue Shield 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.

CHECK MY
INSURANCE TOOL
1

Choose your plan, state, and insurance company below.

Can’t find your insurance company/plan or have updated info?


Read and click below for additional weight loss surgery insurance details.

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

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

    • BMI 35 – 39.9 AND one of the following
      • Hypertensive cardiovascular disease
      • Coronary heart disease
      • Pulmonary hypoventilation
      • Hypertension,
      • Hypercholesterolemia
      • Dyslipidemias
      • Diabetes
      • Sleep apnea
      • Degenerative arthritis of weight-bearing joints or other weight related arthropathies
      • Metabolic syndrome

    Use this BMI Calculator to check your body mass index…

  4. The condition of morbid obesity must be of at least 5 years duration
  5. A letter of support from the physician currently providing primary care to the member and who is familiar with his/her attempts at weight reduction, medical history and current health status (including obesity issues) is also necessary for the review process
  6. History of rigorous attempts at weight reduction:
    • There must be written evidence of a weight loss history, either by the bariatric surgeon, primary care physician or nutritionist. This documentation should include the name of the weight loss program, length of participation in the program and any weight loss achieved. At least one program must have been a supervised weight loss program
    • Weight loss attempts need not be continuous, but a minimum total of six months is required
      • If the patient has had no previous attempts at medical weight loss, participation for a minimum of six months in a preoperative bariatric surgery weight loss program is required
      • If past prior attempts of weight loss are remote (greater than 5 years), then the patient is required to participate, for a minimum of six months in a preoperative bariatric surgery weight loss programd
  7. There must be no significant liver, kidney, or gastrointestinal disease present. The presence of non-alcoholic steatohepatitis or “fatty liver”, which is associated with morbidly obese patients, would not be considered significant liver disease in this instance
  8. Treatable metabolic causes for obesity (e.g., adrenal or thyroid disorders) have been addressed
  9. Patients with a history of alcohol or substance abuse will not be considered unless there is a record of at least six months of abstinence. If there has been six months of abstinence, this condition must be addressed in a psychiatric consultation
  10. Patients must be screened by their physician for major psychopathology

Laparoscopic Adjustable Gastric Banding

Based upon our criteria and assessment of peer-reviewed literature, the surgical management of morbid obesity by laparoscopic adjustable gastric banding is considered medically appropriate in the following circumstances:

  • The patient must meet all the requirements listed above in Policy Statement I, A-H
  • The dietary history does not include a large consumption of high caloric liquids (e.g., milk shakes) or sweets
  • The patient has no significant history of esophageal or gastric disease (please note contraindications to adjustable gastric banding listed in the rationale section)
  • The patient must participate in a pre-operative bariatric program that requires a 5% weight loss to demonstrate commitment to behavioral and dietary changes. The 5% weight loss will be measured from the date of the patient’s initial visit to the bariatric surgeon to the date of the request for pre-authorization of the adjustable gastric banding procedure

Revision Requirements

A revision or removal of a laparoscopic adjustable gastric band is considered medically necessary for complications or for a technical failure. Examples of complications and technical failures that may warrant a revision, removal, or conversion to another procedure include:

  • Band slippage
  • Band erosion
  • Infection
  • Esophageal dilation
  • Dysphagia
  • Heartburn/reflux
  • Displaced band
  • Port dislocation
  • Too tight a band creating food passage problems
  • Band intolerance (e.g., pain, vomiting)
  • Port and/or catheter leakage

A revision or conversion to another medically appropriate procedure because of unsatisfactory weight loss due to technical failure of the primary bariatric procedure such as pouch dilation or an initial pouch size that is too large is considered medically appropriate if there is documentation regarding all of the following submitted with the request:

  • Primary procedure was initially successful in inducing weight loss
  • Patient has remained compliant to the 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.

Excellus Blue Cross Blue Shield 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.

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

Following are a list of Excellus Blue Cross Blue Shield 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.

Advertisement
Excellus Blue Cross Blue Shield Weight Loss Surgery

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

Procedures That Are NOT Covered

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

Excellus Blue Cross Blue Shield Weight Loss Surgery

If Excellus Blue Cross Blue Shield 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 Excellus Blue Cross Blue Shield 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: