BCBS of Alabama Weight Loss Surgery – How to Avoid a Denial

In order to be approved by Blue Cross Blue Shield Alabama for bariatric surgery, you must meet the following criteria:

For Gastric Restrictive Procedures

Restrictive procedures include gastric banding/lap band, gastric bypass, gastric sleeve and vertical banded gastroplasty – see the Covered Procedures section below for links to our specific procedure explanation pages

1. BMI of 40 or greater, or BMI of 35 or greater with one or more of the following co-morbid conditions:
   • HTN on optimal drug therapy
   • atherosclerotic cardiovascular disease
   • diabetes (must be treated with insulin or oral agents)
   • pulmonary hypertension
   • severe obstructive sleep apnea (RDI of 50 or greater).
2. The condition of morbid obesity (BMI of 40 or greater 35 or greater with presence of comorbid conditions) must be of at least 3 years duration.
   • There must be documentation in medical records by a primary care or attending physician of patient height and weight for the past 3 years. A letter from the primary care physician and dated photographs will be considered in lieu of recorded heights and weights. Random reviews of these patients’ charts for accuracy of stated information will be conducted.

Use this BMI Calculator to check your body mass index…

3. Documentation must be present of participation in medically supervised weight loss program.
   • For purposes of coverage, we (BCBS) recognize medical supervision of the diet and activity program by practicing MD’s who are not bariatric surgeons, such as family practitioners, internists, and other primary care specialties (medically supervised weight loss or activity programs generally are not a covered benefit).
   • Documentation provided by these health care providers will be recognized in the review process. At least one attempt must occur during the one year prior to request for surgery or date of surgery. Documentation must support participation in the program for six consecutive months.
   • The following criteria must be met for this participation:
     • Documentation of participation in a physician supervised program of nutrition and increased physical activity (including dietitian consultation, low calorie diet, increased physical activity and behavioral modification). Documentation of program participation must appear in the medical record no less than monthly for a period of 6 consecutive months by the attending physician. Documentation should include comments by the physician regarding patient progress or lack of progress. A letter does not meet this requirement. There must be medical records to document medically supervised weight loss attempts
     • Medical record documentation of a 6 consecutive month, nutrition-led weight loss program (Weight Watchers, LA Weight Loss, Jenny Craig, EatRight, etc.) with a minimum of 3 physician visits during that 6 month period documenting medical supervision, Not acceptable are self-directedprograms such as joining a gym, Atkins’ diet, calorie counting, low fat,cutting back, internet programs, etc.
4. A complete history and physical must be performed by the bariatric surgeon to include height and weight.
5. The patient must be at least 18 years of age.
6. Due to the surgical morbidity associated with concomitant pulmonary disease coverage will not be provided for anyone who has smoked in less than eight weeks prior to surgery.

For Malabsorptive Procedures (Duodenal Switch Surgery)

Open or laparoscopic biliopancreatic bypass (i.e., the Scopinaro) procedure with duodenal switch meets Blue Cross and Blue Shield of Alabama’s medical criteria for coverage fortreatment of the morbidly obese patients with BMI of 50 or more when the following criteria are met:

1. Documentation must be present of participation in medically supervised weight loss program.
   • For purposes of coverage, we (BCBS) recognize medical supervision of the diet and activity program by practicing MD’s who are not bariatric surgeons, such as family practitioners, internists, and other primary care specialties. Documentation provided by these health care providers will be recognized in the review process.
   • At least one attempt must occur during the one year prior to request for surgery or date of surgery. Documentation must support participation in the program for six consecutive months. The following criteria must be met for this participation:
     • Documentation of participation in a physician supervised program of nutrition and increased physical activity (including dietitian consultation, low calorie diet, increased physical activity and behavioral modification). Documentation of program participation must appear in the medical record by the attending physician. Documentation should include comments by the physician regarding patient progress or lack of progress. A letter does not meet this requirement. There must be medical records to document medically supervised weight loss attempts
     • Acceptable with medical record documentation of medical supervision are: Weight Watchers, LA Weight Loss, Jenny Craig, EatRight etc. Not acceptable are self-directed programs such as joining a gym, Atkins’ diet, calorie counting, low fat, cutting back, internet programs, etc.
2. A complete history and physical must be performed by the bariatric surgeon to include height and weight.
3. The patient must be at least 18 years of age.
4. Due to the surgical morbidity associated with concomitant pulmonary disease coverage will not be provided for anyone who has smoked in less than eight weeks prior to surgery

See our Duodenal Switch page for more information about this procedure.

Revision Requirements

Gastric Surgery Revision

Revision of a prior bariatric procedure (excluding adjustable gastric banding) meets Blue Cross and Blue Shield of Alabama’s medical criteria for coverage with documented evidence of one or more of the following:

• Weight loss of 20% or more below the ideal body weight following bariatric surgery,
• Vomiting (bilious)
• Stomal dilatation documented by either upper gastrointestinal (UGI) series or esophagogastroduodenoscopy (EGD)
• Pouch dilatation documented by either upper gastrointestinal (UGI) series or esophagogastroduodenoscopy (EGD)
• Stomal stenosis after vertical gastric banding, documented by endoscopy, with vomiting or weight loss of 20% or more below the ideal body weight
• Staple line failure, documented by either upper gastrointestinal (UGI) series or esophagogastroduodenoscopy (EGD)
• Severe diarrhea following surgery
• Severe dumping syndrome

The requested procedure must be a Blue Cross and Blue Shield of Alabama covered bariatric surgery/procedure

Gastric Surgery Revision

Revision or removal of adjustable gastric restrictive device meets Blue Cross and BlueShield of Alabama’s medical criteria for coverage for the following indications:

• Band erosion or slippage
• Infections around the port site

Elective removal of the adjustable gastric restrictive device does not meet Blue Cross andblue Shield of Alabama’s medical criteria for coverage.

Repeat surgery for morbid obesity for other than the stated surgical complications does not meet Blue Cross and Blue Shield of Alabama’s criteria for coverage.

Please verify contract benefits for coverage of bariatric surgery and complications.

Contact Blue Cross Blue Shield Alabama to Ask About Bariatric Surgery

• By Phone:
• Individual & Family Products: 1-888-267-2955
• Business & Employer Plans: 1-855-525-7283
• Federal Employees: 1-800-492-8872
• Contact Blue Cross Blue Shield Alabama
• Full Bariatric Surgery Medical Policy for Blue Cross Blue Shield Alabama