Weight loss surgery, also known as bariatric surgery, has become an increasingly popular option for those struggling with severe obesity and weight-related health issues.
Procedures like gastric bypass, sleeve gastrectomy, and duodenal switch help people achieve significant, sustainable weight loss by restricting food intake and absorption.
However, weight loss surgery comes at a steep price, costing anywhere from $15,000 to $30,000 on average. So does insurance cover it? And what about one of the largest providers – Blue Cross Blue Shield?
I’ll cover all you need to know in this comprehensive guide.
Why Weight Loss Surgery?
For those with a high BMI and obesity-related conditions like heart disease or type 2 diabetes, weight loss surgery can be a life-changing – and potentially life-saving – treatment. Let’s look at some of the key benefits:
Significant and Sustainable Weight Loss
Weight loss surgery is the most effective intervention we have for significant, rapid weight loss in obese individuals. People can lose 50-75% of their excess body weight in the first year post-surgery.
Unlike diet and exercise alone, weight loss surgery offers more long-term, sustainable results.
Resolution of Obesity-Related Health Issues
Losing a substantial amount of weight can essentially “cure” diseases like diabetes and sleep apnea for some patients. One study showed gastric bypass patients saw complete diabetes remission in 57-73% of cases.
Losing weight improves cardiovascular health, fertility, joint pain, and much more.
Improved Quality of Life
Beyond physical health, weight loss surgery leads to better mobility, self-confidence, relationships, and ability to be active and engaged in life. It can have immense social, emotional, and psychological benefits.
So in many cases, weight loss surgery can truly change lives. But there are risks and it’s not for everyone struggling with excess weight. Talk to your doctor about whether you are an appropriate candidate.
Blue Cross Blue Shield Coverage
Now, onto the key question – does insurance cover such an expensive procedure? Blue Cross Blue Shield (BCBS) provides health insurance coverage to about 1-in-3 Americans.
But there is no uniform nationwide policy for covering weight loss operations.
Here are the key things to know about BCBS bariatric surgery coverage:
Varies by Plan Type
Coverage depends firstly on what type of BCBS plan you have. Self-insured plans designed for large employers usually have greater flexibility.
Fully-insured small group and individual plans may exclude weight loss surgery as an excluded cosmetic treatment.
Different Rules for BCBS Companies
BCBS is made up of 36 different local companies that operate independently. So coverage can vary not only by plan type but the state and BCBS company approving claims.
Some states require insurers to cover weight loss surgery while others don’t have protections.
Factors Impacting Approval
Assuming your BCBS plan covers bariatric surgery, you’ll need to meet clinical criteria and follow procedures to get approval. Let’s look at what impacts approval odds.
Next, let’s look at some common requirements.
Weight Loss Surgery Pre-Approval Requirements
Most insurers including BCBS require prior authorization for weight loss operations where you must meet certain evidence-based criteria. Here are some to expect:
BMI & Health Condition Minimums
- BMI >40, or >35 with at least 1-2 obesity-related conditions
- Failed previous non-surgical weight loss attempts
- Physical and mental health evaluation
- Nutritional counseling
Proving surgery is “medically necessary” is key. Additional factors positively impacting approval are:
- Multiple severe health issues BMIs nearing 50+
- Limited mobility/trouble with daily living
- Weight negatively impacting job performance
The process involves extensive medical records submission, documentation of co-morbidities, proving you can comply with post-op requirements, psychological testing, and lab work.
Typical Patient Costs
What about out-of-pocket costs? With insurance, your expenses for bariatric surgery may include:
Deductibles
Deductibles of $1,000+ are common before coverage kicks in. If your plan has a per-person and family deductible, both apply for bariatric surgery.
Coinsurance
Most BCBS plans cover 70-80% after reaching your deductible. You pay the remainder coinsurance up to your out-of-pocket max.
Lifetime Maximums
Some older BCBS plans have lifetime caps on bariatric coverage (e.g. $10,000). Gastric sleeve surgery alone can exceed such caps.
Office Visits & Lab Tests
Pre-approval consultations with your bariatric surgeon, nutritionist, and psychologist have copay or coinsurance costs. Presurgery lab work can run up bills.
Hospital & Facility Charges
Unless you stay extended, hospital fees are usually covered along with surgery charges after deductible. But facility bills can have cost share.
Aftercare & Complications
Band adjustments, post-op nutrition counseling, plastic surgery for excess skin removal – these follow-ups often aren’t covered. Nor are complications.
Talk to your insurer so you know the total cost picture beforehand. Now let’s run through the approval and claims process.
Navigating Bariatric Surgery Claims with BCBS
Here is a step-by-step overview of getting weight loss surgery approved and paid for by Blue Cross Blue Shield insurance:
1. Check Your Plan Benefits
Call the member services number on your BCBS insurance card. Ask:
- Does my plan cover weight loss/bariatric surgery?
- Is prior authorization required?
- What criteria must be met (BMI, disease conditions, etc)?
- Do I have in-network bariatric surgery providers near me?
If your plan excludes coverage, you may need to join a PPO plan or your employer’s self-funded plan in open enrollment assuming they cover bariatric benefits.
2. Get Pre-Approval
Most BCBS plans require prior authorization where your bariatric surgeon submits medical records outlining:
- BMI and documented failed dieting attempts
- Co-morbid conditions (diabetes, sleep apnea, etc)
- Nutritionist reports
- Psychological testing results
This gives BCBS time to verify everything meets evidence-based criteria before surgery costs are incurred.
3. Check Status Frequently
Approval can take up to 30 days. Call your insurer to check status weekly. Provide additional documentation if requested – this can expedite an approval.
4. Schedule Your Bariatric Operation
Once approved, coordinate with your bariatric surgeon’s office on timing. Buy any nutritional supplements needed for post-op diet ahead of time.
5. Pay Required Cost Shares
Pay deductibles, copays or coinsurance required by your insurer upfront. Get bills from all entities (surgeon, anesthesiologist, radiologist, hospital) to send to BCBS.
Submit all itemized bills instead of just the facility’s summary charges. This prevents claim issues down the road.
6. Stick to Follow-Up Protocols
For continued coverage, you must follow all post-op diet, lab work requirements, band fills (if gastric banding), etc. Attend counseling, physical therapy, andprovider visits as directed.
Document everything related to your bariatric care. Keep weight records with the goal most insurers require to show 50% excess body weight loss in 2 years.
Key Takeaways
Whether Blue Cross Blue Shield insurance covers weight loss surgery – and how much they cover – varies widely by plan, state, your condition severity, and ability to follow stringent protocols.
While daunting, this life-changing surgery is worth pursuing given the dramatic health improvements possible.
Just be prepared that even with coverage, you may incur thousands in deductibles, copays or coinsurance costs.
The best path is using in-network bariatric surgery providers. Know what is needed for approval beforehand and actively manage the claims process every step of the way.
Over 120,000 people undergo weight loss operations yearly in the U.S. – you can navigate the insurance maze successfully too.
I hope this guide gives you a great starting point for understanding BCBS bariatric coverage! Let me know if you have any other questions.
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