Independence BCBS Weight Loss Surgery - How to Avoid a Denial

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

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Independence Blue Cross 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 Independence Blue Cross 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
      • Hypertension
      • Coronary artery disease
      • Type 2 diabetes mellitus
      • Severe Sleep Apena
      • Pseudotumor cerebri
      • Severe nonalcoholic steatohepatitis

    Use this BMI Calculator to check your body mass index…

  4. Has a documented failed history of medical weight loss
  5. Is not currently pregnant and/or breast feeding and has agreed to avoid pregnancy for at least one year postoperatively
  6. Has participated in preoperative surgical care, directed and provided by the member’s physician or through a multidisciplinary surgical preparatory regimen, including all of the following components:
    • A thorough medical history and physical examination
    • Consultation and instruction by a professional provider on low-calorie diets and an exercise program based on the individual’s capability
    • An evaluation by a licensed mental health professional provider that specifically evaluates all of the following: any mental health or substance abuse conditions; the emotional readiness and ability of the individual to make and sustain lifestyle changes; and the adequacy of the individual’s support system

Adolecents Requirements

Independence Blue Cross will cover adolescent bariatric surgery if it is deemed medically necessary if the following conditions are met:

  1. A BMI that is:
    • Greater than or equal to 50
    • Between 40 and 50 in conjunction with one or more less serious comorbidities
      • Hypertension
      • Insulin resistance
      • Glucose intolerance
      • Dyslipidemia
      • Clinically significant sleep apena
    • Between 35 and 40 in conjunction with one or more major obesity-related comorbidities:
      • Type 2 diabetes mellitus
      • Moderate to severe obstructive sleep apnea
  2. Has a documented failed history of medical weight loss
  3. Has participated in preoperative surgical care, directed and provided by the member’s physician or through a multidisciplinary surgical preparatory regimen, including all of the following components:
    • A thorough medical history and physical examination
    • Consultation and instruction by a professional provider on low-calorie diets and an exercise program based on the individual’s capability
    • An evaluation by a licensed mental health professional provider specializing in pediatric care that specifically evaluates all of the following:
      • Any mental health or substance abuse conditions
      • The emotional readiness and ability of the individual to make and sustain lifestyle changes
      • The adequacy of the individual’s support system
  4. Has attained a sufficient level of matuirty as defined by:
    • Tanner Stage IV
    • Ninety-five percent of adult height based on estimates from radiologic bone age

Revision Requirements

Revision surgery may be consider medically neccesary in the following circumstances:

  1. Conversion to another procedure may be covered if:
    • Not lost up to 50% of excess weight loss while following diet and exercise requirements
    • An examination by a licensed mental health professional that evaluates:
      • Any mental health or substance abuse conditions
      • Emotional readiness and ability of the individual to make and sustain lifestyle changes
      • Adequacy of the individual’s support system
  2. A pouch dilation, where the pimary procedure was successful in inducing weight loss before the pouch developed, and the nutrition and exercise requirements were followed
  3. Replacement of an adjustable band due to complications (e.g., port leakage, slippage) that cannot be corrected with band manipulation or adjustments

If your Lap-Band procedure failed because of a pouch dilation a Lap-Band Revision may be considered medically neccessary if you followed your diet and exercise program and had successful weight loss prior to the pouch developing.

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.

Independence Blue Cross 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.

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

Following are a list of Independence Blue Cross 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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Independence Blue Cross Weight Loss 
 Surgery

Please see below for the procedures Independence Blue Cross 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 Independence Blue Cross:

Procedures That Are NOT Covered

The following procedures are NOT covered by Independence Blue Cross:

Independence Blue Cross Weight Loss Surgery

If Independence Blue Cross 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 Independence Blue Cross 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: