Out of Pocket Bariatric Surgery on Blue Cross Blue Shield Mn

BCBS Minnesota Weight Loss Surgery Requirements & Free Insurance Check

BCBS Minnesota Weight Loss Surgery Requirements & Free Insurance Check

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

First, try our insurance tool to quickly check your insurance coverage:

Read and click below for additional weight loss surgery insurance details.

TABLE OF CONTENTS

Click on any of the topics below to jump directly to that section

1. Coverage Requirements
2. Coverage Plans
3. Covered Procedures
4. Appealing a Denial
5. Find a Weight Loss Surgeon

SECTION SUMMARY:

• 35+ Body Mass Index (BMI)
• Documentation of failed diet attempts
• Psychological evaluation

READ THIS FIRST

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.

Find a Weight Loss Surgeon

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 Blue Cross Blue Shield Minnesota 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
• a Body Mass Index (BMI) greater than 40

Or

• BMI 35 – 39.9 AND one of the following
• Hypertension refractory to standard drug regimens
• Cardiovascular disease
• Type 2 diabetes mellitus
• Severe, progressive degenerative joint disease with limitation of motion in a weight-bearing joint or the lumbosacral spine
• Obstructive sleep apnea
• Severe persistent asthma

Use this BMI Calculator to check your body mass index…

3. The condition of morbid obesity must be of at least two years duration and must be present during the two years prior to surgery. Because attempts to lose weight over this two-year time period may cause small uctuations around the required levels for the patient's BMI, the two-year time period will not necessarily start over, or be prolonged, if small uctuations occur.
4. Over the last year prior to surgery, the patient has actively participated in a structured, nonsurgical weight loss program (i.e., a program that provides diet, exercise, and behavior modi cation strategies through individual or group counseling), for a total of six months with failure to achieve weight loss goals or maintain weight loss. Participation in one of these programs must be at least 3 consecutive months in duration. Participation must be monitored by the primary care physician providing medical oversight for the patient and must be documented in the medical record.
5. The patient must be evaluated preoperatively by an eligible licensed Mental Health Professional to ensure the absence of signi cant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations.
6. he physician requesting authorization for the surgery must con rm that the patient's treatment plan includes a surgical preparatory program addressing all the following components in order to improve outcomes related to the surgery and to establish the member's ability to comply with post-operative medical care and dietary restrictions:
• Pre-operative and post-operative dietary plan
• Behavior modi cation strategies
• Counseling and instruction on exercise and increased physical activity
• Ongoing support for lifestyle changes necessary to make and maintain appropriate choices that will reduce health risk factors and improve overall health

Adolecents Requirements

The surgical treatment of morbid obesity may be considered medically necessary for patients under the age of 18 if the following conditions are met:

1. BMI of 50+
2. BMI of 40-49.9 with at least one of the following comorbid conditions:
• Type 2 diabetes
• Obstructive sleep apnea
• Hypertension, refractory to standard treatment
• Pseudotumor cerebri
• Polycystic ovarian syndrome (PCOS)
• Nonalcoholic steatohepatitis (NASH) proven on liver biopsy or through a combination of elevated liver function tests and hepatic steatosis on liver imaging
3. Absence of a previous history of genetic or syndromic obesity, such as Prader-Willi syndrome
4. Patient has attained Tanner IV or V pubertal development and one of the following
• Bone age of 13+ in girls or 15+ years in boys
• Attainment of 95% of adult height based on estimates of bone age
5. The condition of morbid obesity must be of at least two years duration and must be present during the two years prior to surgery. Because attempts to lose weight over this two-year time period may cause small uctuations around the required levels for the patient's BMI, the two-year time period will not necessarily start over, or be prolonged if small uctuations occur.
6. Over the last year prior to surgery, the patient has actively participated in a structured, nonsurgical weight loss program (i.e., a program that provides diet, exercise, and behavior modi cation strategies through individual or group counseling), for a total of six months with failure to achieve weight loss goals or maintain weight loss. Participation in one of these programs must be at least 3 consecutive months in duration. Participation must be monitored by the primary care physician providing medical oversight for the patient and must be documented in the medical record.
7. The patient must be evaluated preoperatively by an eligible licensed Mental Health Professional to ensure the absence of signi cant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations. The Mental Health Professional must meet the Minnesota Department of Human Services quali cations, as set forth in Minn.Stat. §245.4871, subd. 27 (2013). The evaluation must also address the following issues:
• Patient's ability to provide informed assent without coercion
• Family and social support
• Assessment of the use of any pharmacologic agents (e.g., anti-psychotic medications) that may contribute to obesity
8. TThe physician requesting authorization for the surgery must con rm that the patient's treatment plan includes an adolescent-speci c surgical preparatory program addressing all the following components in order to improve outcomes related to the surgery and to establish the member's ability to comply with post-operative medical care and dietary restrictions:
• Pre-operative and post-operative dietary plan
• Behavior modi cation strategies
• Counseling and instruction on exercise and increased physical activity
• Ongoing support for lifestyle changes necessary to make and maintain appropriate choices that will reduce health risk factors and improve overall health

Revision Requirements

Revision bariatric surgery or conversion of one type of bariatric surgery to a different procedure may be considered medically necessary using one of the procedures using the following criteria:

1. Treatment of surgical complications following the original bariatric surgery. Complications may include, but are not limited to:
• Staple-line failure
• Obstruction
• Stricture
• Malnutrition
• Erosion or band slippage
• Pouch dilation
• Stoma ulcer
2. Inadequate weight loss following the original surgery when all the following criteria are met:
• Patient was compliant with the postoperative dietary and exercise program
• BMI:
• Adult patient currently has a BMI of 40+ with a severe obesity-related co-morbid condition
• Adult patient currently has a BMI of 50+ with a minor obesity-related co-morbid condition
• At least two years have elapsed since the original bariatric surgery
3. Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorization.

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.

Blue Cross Blue Shield Minnesota Contact Information and Full Medical Policy on Bariatric Surgery

• By Phone: 1-800-262-0823
• Contact Blue Cross Blue Shield Minnesota
• Full Bariatric Surgery Medical Policy for Blue Cross Blue Shield Minnesota

SECTION SUMMARY:

• Coverage Through Your Employer
• Individual & Family Plans
• Medicare

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.

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

Following are a list of Blue Cross Blue Shield Minnesota 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:

• Your local surgeon will usually be willing check your insurance for free. Click here to find a surgeon near you, then call or email them to request a free insurance review.
• Ask your Human Resources department
• Contact your insurance company directly using the phone number on your insurance ID card

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:

• Weight Loss Surgery Insurance Secrets: Revised List (good tips even if your policy does not include bariatric surgery)
• Financing bariatric surgery (all of your options)

• 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:

• Gastric sleeve surgery
• Gastric bypass surgery
• Gastric banding (lap band surgery) (LASGB)
• Duodenal switch surgery (DS)
• Biliopancreatic diversion surgery (BPD)

However, special Medicare-specific criteria apply. Click here to learn more about Medicare bariatric surgery coverage.

SECTION SUMMARY:

• General Appeal Instructions
• Appeal Details Specific to Blue Cross Blue Shield Minnesota

If Blue Cross Blue Shield Minnesota 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 Blue Cross Blue Shield Minnesota to learn how to proceed.

05.

Find A Top Weight Loss Surgeon

SECTION SUMMARY:

• Ask for a free insurance check or cost quote
• Attend a free seminar or webinar
• Schedule a phone or in-person consultation (both often free)

Search the weight loss surgeon directory below to ask a surgeon about a free insurance check by country and region:

• Back to Bariatric Surgery Insurance Requirements
• Back to Bariatric Surgery Source Home Page from Blue Cross Blue Shield Minnesota Weight Loss Surgery Coverage

^* Disclaimers:

Content

: The information contained in this website is provided for general information purposes and your specific results may vary depending on a variety of circumstances. It is not intended as nor should be relied upon as medical advice. Rather, it is designed to support, not replace, the relationship that exists between a patient/site visitor and his/her existing physician(s). Before you use any of the information provided in the site, you should seek the advice of a qualified medical, dietary, fitness or other appropriate professional.

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