Highmark Health Weight Loss Surgery - How to Avoid a Denial

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

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List of Highmark Health Insurance Companies

Highmark Health’s policy on weight loss surgery also apply to their subsidiary insurance companies, including:

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

Highmark Health Weight Loss Surgery

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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 Highmark Health for bariatric surgery in the United States, you must meet the following criteria:

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

    • BMI 35 – 39.9 AND one of the following
      • Hypertension
      • Cardiovascular heart disease
      • Dyslipidemia
      • Diabetes mellitus type II
      • Sleep apnea

    Use this BMI Calculator to check your body mass index…

  4. The patient has received non-surgical treatment (e.g., dietitian/nutritionist consultation, low calorie diet, exercise program, and behavior modification) and attempts at weight loss have failed.
  5. The patient must participate in and meet the criteria of a structured nutrition and exercise program. This includes dietitian/nutritionist consultation, low calorie diet, increased physical activity, behavioral modification, and/or pharmacologic therapy, documented in the medical record. This structured nutrition and exercise program must meet ALL of the following criteria:
    • The nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists
    • The nutrition and exercise program(s) must total six visits or more during a period of six consecutive months
    • The nutritional and exercise program must occur within two years prior to the surgery
    • The patient’s participation in a structured nutrition and exercise program must be documented in the medical record by an attending physician who supervised the patient’s progress. A physician’s summary letter is not sufficient documentation. Documentation should include medical records of the physician’s on-going assessments of the patient’s progress throughout the course of the nutrition and exercise program. For patients who participate in a structured nutrition and exercise program, medical records documenting the patient’s participation and progress must be available for review
  6. The patient must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery. The patient’s medical record documentation should indicate that all psychosocial issues have been identified and addressed.
  7. Patient selection is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. The member’s understanding of the procedure, and ability to participate and comply with life-long follow-up and the life-style changes (e.g., changes in dietary habits, and beginning an exercise program) are necessary to the success of the procedure.

Adolecents Requirements

The eligible bariatric surgical procedures listed above unless otherwise specified are covered for members under the age of 18 years when they meet all of the following patient selection criteria:

  1. Attainment or near-attainment of physiologic/skeletal maturity at approximately, age 13 in girls and 15 for boys. (The patient has attained Tanner 4 pubertal development and final or near-final adult height (e.g., ≥ 95 %) of adult stature).
  2. The patient is morbidly obese defined as a BMI of 50+ or severely obese defined as a BMI 40+ with serious comorbidities:
    • Severe obstructive sleep apnea
    • Pickwickian syndrome
    • Obesity related cardiomyopathy
    • Pulmonary hypertension
    • Dltwocumented coronary artery disease
    • Pseudotumor cerebri
    • Type II Diabetes
  3. The patient has received non-surgical treatment (e.g., dietitian/nutritionist consultation, low calorie diet, exercise program, and behavior modification) and attempts at weight loss have failed.
  4. The patient must participate in and meet the criteria of a structured nutrition and exercise program. This includes dietitian/nutritionist consultation, low calorie diet, increased physical activity, behavioral modification, and/or pharmacologic therapy, documented in the medical record. This structured nutrition and exercise program must meet ALL of the following criteria:
    • The nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists
    • The nutrition and exercise program(s) must total six visits or more during a period of six consecutive months
    • The nutritional and exercise program must occur within two years prior to the surgery
    • The patient’s participation in a structured nutrition and exercise program must be documented in the medical record by an attending physician who supervised the patient’s progress. A physician’s summary letter is not sufficient documentation. Documentation should include medical records of the physician’s on-going assessments of the patient’s progress throughout the course of the nutrition and exercise program. For patients who participate in a structured nutrition and exercise program, medical records documenting the patient’s participation and progress must be available for review
  5. The patient must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery. The patient’s medical record documentation should indicate that all psychosocial issues have been identified and addressed.
  6. The patient must be able to show decisional capacity and maturity in the psychological evaluation and provide informed assent for surgical management.
  7. The patient must be capable and willing to adhere to nutritional guidelines postoperatively.
  8. The patient must have a supportive and committed family environment.
  9. Patient selection is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. The member’s understanding of the procedure and ability to participate and comply with life-long follow-up and the life-style changes (e.g., changes in dietary habits, and beginning an exercise program) are necessary to the success of the procedure.

Revision Requirements

Surgical repair following gastric bypass and gastric restrictive procedure may be considered medically necessary when there is documentation of a surgical complication related to the original surgery, such as a:

  • Fistula
  • Obstruction
  • Erosion
  • Disruption/leakage of a suture/staple line
  • Bad herniation
  • Pouch enlargement with vomiting

Repeat surgical procedures for revision or conversion to another surgical procedure (that also may be considered medically necessary within this document) for inadequate weight loss, (that is, unrelated to a surgical complication of a prior procedure) may be considered medically necessary when all the following criteria are met:

  • The individual continues to meet all the medical necessity criteria for bariatric surgery
  • There is documentation of compliance with the previously prescribed postoperative dietary and exercise program
  • Two years following the original surgery, weight loss is less than 50% of pre-operative excess body weight and weight remains at least 30% over ideal body weight (taken from standard tables for adult weight ranges based on height, body frame, gender and age, an example is available from the National Heart Lung and Blood Institute [NHLBI]

Revision of a sleeve gastrectomy is medically necessary for the following:

  • Intractable GERD or reflux may require revision of a sleeve into a gastric bypass, by dividing the sleeve proximally, then constructing a Roux limb, then a gastrojejunostomy
  • Persistent narrowing or stricture at a portion of the sleeve may make resection of that segment necessary or revision into a gastric bypass
  • A chronic leak may mandate resection or revision
  • Inadequate weight loss, or weight regain due to dilation of the sleeve
  • Revision to a gastric bypass or to a duodenal switch for inadequate weight loss

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.

Highmark Health 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.

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

Following are a list of Highmark Health 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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Highmark Health Weight Loss Surgery

Please see below for the procedures Highmark Health 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 Highmark Health:

Procedures That Are NOT Covered

The following procedures are NOT covered by Highmark Health:

Highmark Health Weight Loss Surgery

If Highmark Health 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 Highmark Health 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: