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

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

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

  1. Patient must be 18 years or older
  2. Diagnosis of Morbid obesity, defined as
  3. Or

    • BMI 35 – 39.9 AND one of the following
      • Established Coronary Heart Disease, which includes:
        • History of myocardial infarction
        • History of angina pectoris (stable or unstable)
        • History of coronary artery surgery
        • History of angioplasty
      • Other Atherosclerotic Diseases, such as:
        • Peripheral arterial disease
        • Abdominal aortic aneurysm
        • Symptomatic carotid artery disease
        • Medically refractory hypertension BP greater than 140/90 despite optimal medical management
      • Type 2 Diabetes Uncontrolled by Pharmacotherapy
      • Sleep apnea with a respiratory disturbance index (RDI) of 16 to 30 (moderate) or apnea-hypopnea index (AHI) greater than 30 (severe) as documented by a laboratory based polysomnography>

    Use this BMI Calculator to check your body mass index…

  4. Physician supervised weight reduction program which includes:
    • A program of at least six consecutive months’ duration within the two year period prior to surgery being considered
    • Evidence of active participation in a program documented in member’s medical record. Evidence of active participation includes:
    • Clinical records that reflect monitoring and supervision of a physician directed weight loss program with exercise component such as MediFast, OptiFast
    • Clinical records that reflect supervision and monitoring of a nutrition and exercise program such as Weight Watchers
  5. Psychological evaluation by a licensed mental health provider to establish emotional stability and the ability to comply with post-surgical limitations

Adolecents Requirements

Bariatric surgery in adolescents may be considered medically necessary according to the same weight-based criteria used for adults, but greater consideration should be given to psychosocial and informed consent issues. In addition, any devices used for bariatric surgery must be in accordance with the FDA-approved indications for use.

Revision Requirements

Revision surgery to address perioperative or late complications of a bariatric procedure is considered medically necessary. These include, but are not limited to:

  • 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 (documented by upper gastrointestinal examination or endoscopy) 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.

Premera 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.

Premera 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 Premera 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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Premera Blue Cross Weight Loss Surgery

Please see below for the procedures Premera 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 Premera Blue Cross:

Procedures That Are NOT Covered

The following procedures are NOT covered by Premera Blue Cross:

  • Gastric Balloon
  • vBloc Therapy
  • AspireAssist
  • Vertical Banded Gastroplasty
  • Mini Gastric Bypass Surgery
  • Biliopancreatic bypass without duodenal switch
  • Long-limb gastric bypass procedure (i.e., >150 cm)
  • Two-stage bariatric surgery procedures (e.g., sleeve gastrectomy as initial procedure followed by biliopancreatic diversion at a later time)
  • Endoscopic procedures (e.g., insertion of the StomaphyX™ device) as a primary bariatric procedure or as a revision procedure, (i.e., to treat weight gain after bariatric surgery to remedy large gastric stoma or large gastric pouches)
  • Any procedure for patients with a body mass index less than 35
Premera Blue Cross Weight Loss Surgery

If Premera 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 Premera 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: