Horizon BCBS of NJ Weight Loss Surgery - How to Avoid a Denial

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

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Horizon Blue Cross Blue Shield of New Jersey 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 Horizon Blue Cross Blue Shield of New Jersey for bariatric surgery in the United States, you must meet the following criteria:

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

    • BMI 35 – 39.9 AND one of the following
      • Coronary artery disease
      • Obesity-related cardiomyopathy
      • Congestive heart failure
      • Obstructive sleep apnea
      • Pickwickian syndrome
      • Obstructive sleep apnea
      • Insulin resistance or frank diabetes mellitus
      • Obstructive sleep apnea
      • Clinically significant asthma
      • Chronic venous insufficiency of the lower extremities
      • Gastroesophageal reflux disease (GERD)
      • Pain and limitation of motion in any weight-bearing joint or the spine
      • Hypertension
      • Pseudotumor cerebri
      • Polycystic ovarian syndrome
      • Metabolic syndrome
      • Hyperlipidemia (hypercholesterolemia and/or hypertriglyceridemia)
      • Non-alcoholic fatty liver (NASH)
      • Osteoarthritis
      • Depression

    Use this BMI Calculator to check your body mass index…

  4. Within the 12 months prior to the time of surgery, the member must meet all of the following requirements:
    1. Copies of original medical records documenting previous participation in non-surgical weight loss program or diet program/plan (e.g., Weight Watchers, Jenny Craig)
    2. Copies of original medical records documenting participation in an organized multidisciplinary surgical preparatory regimen 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. The regimen should provide guidance on diet, physical activity, and behavioral and social support prior to and after the surgery
    3. Copies of original medical records documenting pre-operative psychological evaluation and clearance for bariatric surgery provided by a licensed mental health care professional familiar with the implications of weight reduction surgery

Adolecents Requirements

Bariatric surgery is NOT considered medically necessary for members under 18 years of age unless the member has already achieved full skeletal growth and has a life threatening co-morbidity (e.g., pseudotumor cerebri, severe sleep apnea, uncontrollable hypertension, incapacitating musculoskeletal disease, etc.)

Revision Requirements

Repeat bariatric surgery or any subsequent modification requires supporting documentation which should at least include a clear explanation of the clinical circumstances as to why the procedure failed, the member’s BMI, and the results of any diagnostic tests or studies performed.

Since members are expected to be compliant with the postoperative requirements, members who have failed bariatric surgery because of noncompliance and wish to be considered for revision surgery must be actively reintegrated into an established multidisciplinary bariatric program. These patients must demonstrate compliance to the bariatric surgeon through enrollment in a multidisciplinary bariatric program including psychological intervention nutritional counseling, and support group attendance.

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.

Horizon Blue Cross Blue Shield of New Jersey 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.

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

Following are a list of Horizon Blue Cross Blue Shield of New Jersey 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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Horizon Blue Cross Blue Shield of New Jersey Weight Loss Surgery

Please see below for the procedures Horizon Blue Cross Blue Shield of New Jersey 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 Horizon Blue Cross Blue Shield of New Jersey:

Procedures That Are NOT Covered

The following procedures are NOT covered by Horizon Blue Cross Blue Shield of New Jersey:

Horizon Blue Cross Blue Shield of New Jersey Weight Loss Surgery

If Horizon Blue Cross Blue Shield of New Jersey 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 Horizon Blue Cross Blue Shield of New Jersey 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: