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Anthem Blue Cross Blue Shield’s Requirements For Weight Loss Surgery

For persons with health coverage from Anthem Blue Cross Shield, you’ll be delighted to know that it will cover weight loss surgery.

Obesity Coverage feels very strongly that morbid obesity is a serious illness and that all insurance companies need to cover the life-saving techniques. The majority of the Blue Cross Blue Shield network has some kind of weight loss surgery coverage.

Bear in mind that employers have the option of opting-out of any weight loss surgery insurance coverage, which means employee health policies will not offer it. Opting-out will save the company money on premiums. However, even when a policy excludes the weight loss surgery, if BCBS can be shown these kinds of surgeries are medically important for one’s health, the exclusion can be appealed.

Important: Blue Cross of California is Anthem BCBS’ trade name, which means the criteria for the surgery will be the same.

Pre-Approval Requirements For Anthem BCBS

To be approved for the weight loss surgery, you must meet the minimum requirements:

  • 40+ Body Mass Index (BMI)
  • 35+ BMI with two conditions
  • 18 years old or older
  • Active partaking and certification of non-surgical weight loss techniques
  • Letter from primary care physician
  • Weight loss surgeon’s consult and recommendation
  • Nutritional evaluation
  • Psychological evaluation

8 Policies Included In Weight Loss Coverage

  • Blue Cross California
  • Blue Cross Georgia
  • Blue Cross Kentucky
  • Blue Cross Missouri
  • Blue Cross New York Empire
  • Blue Cross Ohio
  • Blue Cross Virginia
  • Blue Cross Wisconsin

What Are The Kinds Of Bariatric Surgeries Anthem BCBS Covers

Some large insurance companies have started covering gastric sleeves. However, this procedure is considered experimental and is not covered. The following surgeries are covered:

  • Duodenal Switch
  • Gastric Banding (Realize Band or Lap Band)
  • Gastric Sleeves
  • Laparoscopic Gastric Bypass
  • Open Gastric Bypass Surgery

Will Anthem BCBS Cover Lap Band Fills

Anthem BCBS look at the Lap Band Fills as a medical necessity when it must be used to attain proper weight loss levels. For example, you had an modifiable gastric banding procedure that met every criteria for it. If cash paid for the weight loss procedure, the insurance will not cover continuous lap band fills.

3 Procedures Not Covered

  • Banded vertical gastroplasty
  • Mini-gastric bypass
  • Any experimental weight loss technique

Will A Second Surgery Be Covered If Gastric Banding Fails (Revisions)

A second surgery can be paid for so long as any surgical weight loss procedure that didn’t cause an adequate amount of weight loss and was covered by insurance. However, the criteria below still need to be met:

  1. The patient still meets the medical necessity criteria for the bariatric surgery
  2. Documentation regarding the patient’s compliancy with the original post-operative exercise and dietary program
  3. The weight loss is still no more than 50 percent of the pre-operative excess body weight and the patient is still not within 30 percent of the BMI after two years has passed after the first surgery.

A Look At Revisions

Revisions may be covered if documentation of a failure or a surgical complication such as obstruction, fistula or disruption of staple or suture line.

Must You Go To A Center of Excellence and In-Network Physician

The surgery must take place at a Center of Excellence. However, you do not have to use an in-network surgeon. But, the costs will be higher for you if you use an out of network doctor. They will also need to have privileges to perform the weight loss surgery at the accredited Center of Excellence.

You can contact Anthem’s customer service at 1-866-293-2892. You can also look on their website for the email address and contact number.