BCBS Bariatric Surgery Insurance and Treatment Options

If you're considering bariatric surgery, you're likely wondering if your BCBS insurance will cover it. BCBS, or Blue Cross Blue Shield, does offer some coverage for bariatric surgery, but it depends on the specific plan and your individual circumstances.

BCBS considers bariatric surgery a medically necessary procedure for individuals with a BMI of 40 or higher, or those with a BMI of 35-39.9 with at least one obesity-related health condition.

To qualify for coverage, you'll typically need to meet certain requirements, such as attending a pre-surgical weight loss program and having a comprehensive evaluation by a qualified healthcare provider.

BCBS has a list of approved bariatric surgery centers and surgeons, and you can check with your provider to see if they're part of this network.

If you're considering bariatric surgery with BCBS, it's essential to understand what's covered and what's not. BCBS Alabama covers several bariatric procedures, including gastric sleeve or sleeve gastrectomy and gastric bypass and duodenal switch for BMI greater than 50.

Coverage can vary between plans and groups, so it's crucial to check your policy documents or contact BCBS Alabama or our office to find out more. To determine if bariatric surgery is covered by your BCBS Alabama plan, look for the exclusions section in your policy documents.

BCBS Alabama covers several bariatric procedures, including the gastric sleeve, gastric bypass, and duodenal switch. However, some procedures, such as the intragastric balloon, Lap-Band for lower BMI patients, and experimental surgeries like the SIPS procedure and mini gastric bypass, are not yet covered.

Typically, BCBS covers surgeries deemed medically necessary and recognized by medical professionals as effective for significant weight loss. This includes gastric bypass surgery, gastric sleeve surgery, and Lap-Band surgery.

Here's a breakdown of the bariatric surgeries covered by BCBS:

Sleeve gastrectomy is a procedure that reduces the size of your stomach to help with weight loss. It's done by making your stomach smaller to reduce the amount of food you can eat.

Roux-en-Y Gastric Bypass Surgery is another option that helps with weight loss by restricting the amount of food you can eat and reducing the number of calories your body absorbs.

There are also non-surgical options like the Orbera Intragastric Balloon System, which is a 12-month program with a dietitian-directed diet.

If you're considering bariatric surgery, it's essential to know that the American College of Cardiology recommends it for adults with a BMI of 40 or more, or 35 with obesity-related comorbid conditions.

Restrictive treatments for weight loss surgery aim to reduce the amount of food you can eat or limit the calories your body absorbs.

A Sleeve Gastrectomy reduces your stomach to a thin, vertical sleeve, making it smaller to reduce the amount of food you can eat. This procedure is a minimally invasive surgery that helps you lose weight by making your stomach smaller.

Roux-en-Y Gastric Bypass Surgery restricts the amount of food you can eat and reduces the number of calories your body absorbs. This procedure is a minimally invasive surgery that helps you lose weight by limiting the amount of food you can eat and reducing calorie absorption.

Laparoscopic Revision is a minimally invasive procedure for patients who have had a Roux-en-Y gastric bypass and experienced lack of weight loss or weight regain. This procedure can help you regain weight loss or improve your overall health.

The Orbera Intragastric Balloon System is a non-surgical weight loss procedure that includes a twelve-month program with a dietitian-directed diet. This system helps you lose weight by placing a balloon in your stomach to reduce the amount of food you can eat.

Restrictive Procedures:

The American Society for Metabolism isn't directly mentioned in the article sections, but we can learn about bariatric surgery recommendations from other organizations.

Bariatric surgery is a serious consideration for individuals with severe obesity. The American College of Cardiology, American Heart Association, and Obesity Society recommend bariatric surgery for adults with a BMI of 40kg/m or 35kg/m with obesity-related comorbid conditions.

For adolescents, the American Academy of Pediatrics suggests offering referral for evaluation for metabolic and bariatric surgery to those 13 years and older with severe obesity.

Bariatric surgery is not recommended for individuals with certain conditions, including a medically correctable cause of obesity, untreated or poorly controlled substance abuse, concurrent or planned pregnancy, current eating disorder, or inability to adhere to postoperative recommendations.

Here are some specific BMI guidelines to consider:

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has issued guidelines for the management of hiatal hernia, a condition where the stomach bulges up into the chest through an opening in the diaphragm.

In 2013, SAGES recommended that all detected hiatal hernias should be repaired during operations for certain types of bariatric surgery, such as Roux-en-Y gastric bypass, sleeve gastrectomy, and the placement of adjustable gastric bands.

The evidence for this recommendation was based on moderate quality evidence and a weak recommendation.

In 2024, SAGES updated its guidelines and found that there was insufficient evidence to make evidence-based recommendations regarding surgical repair of asymptomatic hiatal hernias or conversion to Roux-en-Y gastric bypass in recurrent hiatal hernias.

However, the guidelines panel suggested that select asymptomatic patients may be offered surgical repair, with specific criteria outlined.

Similarly, the panel suggested that conversion to Roux-en-Y gastric bypass for management of recurrent hiatal hernias may be appropriate in certain patients, with specific criteria also outlined.

The evidence for the routine use of mesh in hiatal hernia repair was equivocal, and the panel deferred making a recommendation.

Preoperative assessments are a crucial part of the bariatric surgery process. Claims for a decision for surgery should be filed with modifier 57.

The pre-operative office visit or consult is considered medically necessary when the surgery is determined to be medically necessary. This visit can be covered even if there's an extended lapse of time between the decision for surgery and the visit.

Pre-operative testing and a pre-operative visit will also be covered if medically necessary and if the surgery is considered medically necessary. The correct diagnoses to report pre-operative testing and evaluations are ICD-10 codes: Z01.810-Z01.811, or Z01.818.

A pre-operative psychological evaluation is not required, but may be covered when requested by the surgeon for individuals with a history of severe psychiatric illness. This includes schizophrenia, borderline personality disorder, suicidal ideation, and severe depression.

These conditions may impair the ability to give consent or be compliant post-operatively, making the psychological evaluation medically necessary. Psychological evaluations should be reported with procedure code 90791 with type service 6.

Understanding what's covered and what's not is crucial when it comes to bariatric surgery and your BCBS insurance policy. Coverage can vary between plans and groups.

You'll likely find information about bariatric surgery coverage in the exclusions section of your policy documents. If it's not listed as a covered benefit, you'll know it's not included.

To confirm the specifics of your coverage, contact BCBS Alabama or our office to get more information.

The Northwestern Medicine Medical and Surgical Weight Loss Center at Huntley Hospital has achieved a significant milestone by obtaining accreditation from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).

This accreditation was a result of a rigorous review process that evaluated the center's facilities, staff, and standards of care. The review process is conducted regularly to ensure that the center maintains high-quality standards.

The MBSAQIP accreditation requires centers to report their outcomes to the program's database, providing a transparent and accountable approach to bariatric surgical care.

Our hospital has been designated as an Optum Center of Excellence, which means we've met high standards for bariatric procedures. This designation indicates we perform more successful procedures than many nearby facilities.

According to Optum, we have a 15 percent lower mortality rate compared to non-designated programs. This is a significant improvement in patient outcomes.

We also have a 16 percent lower inpatient hospital readmission rate, which means patients are more likely to recover at home. This reduces the burden on our healthcare system.

Our reoperation rate for bariatric procedures is 12 percent lower than non-designated programs. This suggests that our patients are experiencing fewer complications.

The average cost per surgical episode is $4,239 lower than non-designated programs. This is a significant cost savings for patients.

Here's a summary of the benefits of being an Optum Center of Excellence: