BCBS Minnesota Weight Loss Surgery Requirements & Free Insurance Check

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.

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