Anthem BCBS – Requirements for Weight Loss Surgery

Many insurance companies, including Anthem Blue Cross Blue Shield (BCBS), believe that morbid obesity is a disease and should be treated as such. Therefore, it is encouraging to know that Anthem BCBS policies generally cover weight loss surgery. In fact, most of the Blue Cross Blue Shield network provides some form of coverage for these life-saving procedures.

Pre-Approval Requirements

To obtain approval for weight loss surgery through Anthem BCBS, the following are the minimum necessary requirements:

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• Body mass index (BMI) of 40 or more or…
• BMI of 35 or more with at least 2 comorbidities.
• Letter from your primary care physician.
• Active participation and documentation of non-surgical methods of weight loss.
• At least 18 years of age (special consideration if under 18 with severe morbid obesity and special circumstances).
• Consultation and recommendation from a weight loss surgeon.
• Psychological evaluation.
• Nutritional assessment.

It’s important to note that your employer can choose to exclude weight loss surgery insurance coverage for their employee policies. This exclusion typically helps the company save money on premiums. Before contacting your BCBS Anthem representative, make sure to review the essential questions to ask your insurance company.

Policies Included in the Coverage

The coverage for weight loss surgery extends to policies such as:

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

Types of Covered Weight Loss Surgeries

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Anthem BCBS covers the following weight loss surgery procedures:

• Laparoscopic gastric bypass
• Open gastric bypass surgery
• Gastric banding, including gastric banding and performed banding
• Duodenal interruption, also known as biliopancreatic diversion
• Gastric sleeve surgery

If you are uncertain about which surgery is suitable for you, you can try taking our bariatric surgery test for guidance.

Lap Band Fillers: Are They Covered?

Anthem BCBS recognizes that gastric banding is medically necessary when it is required to achieve the appropriate level of weight loss. However, this is only applicable if you have had a previous adjustable gastric band procedure that met all the established criteria for that specific procedure. Insurance is unlikely to cover ongoing gastric band fillers if you paid for the procedure out of pocket.

Excluded Procedures

The following weight loss procedures are typically excluded from coverage:

• Mini-gastric bypass
• Vertical banded gastroplasty
• Any other “experimental” weight loss procedure

Second Weight Loss Surgery Coverage

If your initial weight loss surgery, such as gastric band placement, did not result in adequate weight loss, Anthem BCBS may cover a second surgical procedure. However, certain criteria must be met:

• You continue to meet all the medical necessity criteria for bariatric surgery.
• You must provide documentation showing compliance with the original postoperative diet and exercise program.
• At least two years after the original weight loss surgery, your weight loss is still less than 50% of excess preoperative body weight, and your weight is at least 30% of your ideal body weight according to the body mass index (BMI).

Revisions and Complications

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Revisions for weight loss surgery are covered if there is documentation of a failure secondary to a surgical complication. Complications may include fistula, obstruction, or interruption of a suture/staple line.

Center of Excellence Requirement

Anthem BCBS recommends that weight loss surgery should be performed in a center of excellence. This ensures that you receive the highest quality of care and have access to experienced surgeons and medical professionals.

In-Network Weight Loss Surgeons

While it’s not mandatory to use an in-network weight loss surgeon, choosing one within the network may result in significantly lower deductible and out-of-pocket costs. Additionally, you will still need to find a surgeon who has privileges to perform the surgery at an accredited center of excellence for bariatric surgery.

Contact Information for Anthem BCBS

For more information or to inquire about your specific policy, you can reach Anthem BCBS at 1-866-293-2892. Alternatively, you can find their contact number and email address on their website by selecting your state.

Full Weight Loss Surgery Coverage Statement

Please note that Anthem’s full policy on weight loss surgery insurance coverage is no longer available online. It is advisable to call them directly and inquire about whether your policy includes coverage for the CPT code 43775, which identifies gastric bypass surgery. If your policy covers gastric bypass, it should generally cover other bariatric surgery procedures as well.

Source: https://amajon.asia
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