Your Blue Cross Blue Shield Illinois weight loss surgery insurance coverage depends on several factors, all of which are reviewed below.
To request a free insurance check, click here to contact a local surgeon. Alternatively, use the tool below to find out if you have 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
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 policy covers bariatric surgery, click here to contact a surgeon and ask for a free insurance check.
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 Illinois for bariatric surgery in the United States, you must meet the following criteria:
- Growth is completed (generally, growth is considered completed by 18 years of age)
- Diagnosis of Morbid obesity, defined as
- a Body Mass Index (BMI) greater than 40
- BMI 35+ with at least 1 of the following clinically significant obesity-related diseases or complications that are not controlled by best practice medical management
- Hypertension
- Dyslipidemia
- Diabetes mellitus
- Coronary heart disease
- Sleep apnea
- Osteoarthritis
- Documentation from the requesting surgical program that:
- Documentation from the surgeon attesting that the patient has been educated in and understands the post-operative regimen, which should include ALL of the following components:
- Nutrition program, which may include a very low calorie diet or a recognized commercial diet-based weight loss program
- Behavior modification or behavioral health interventions
- Counseling and instruction on exercise and increased physical activity
- Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health
- Patient has completed an evaluation by a masters level or higher behavioral healthcare provider acting within the scope of their licensure under applicable state law, within the 12 months preceding the request for surgery. This evaluation should document:
- The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations
- The absence of any psychological comorbidity that could contribute to weight mismanagement or a diagnosed eating disorder
- The patient’s willingness to comply with preoperative and postoperative treatment plans
Or
Use this BMI Calculator to check your body mass index…
Some of the Reasons for Denial
Even if you meet the 2 requirements outlined in this section, you will likely NOT be approved if any of the following apply to you:
- Patients with mental handicaps that render a patient unable to understand the rules of eating and exercise and therefore make them unable to participate effectively in the post-operative treatment program (e.g., a patient with malignant hyperphagia [Prader-Willi syndrome], which combines mental retardation/intellectual disability with an uncontrollable desire for food)
- Patients with portal hypertension, an excessive hazard with laparoscopic gastric surgery
- Women who are pregnant or lactating
- Patients with serious medical illness in whom caloric restriction could exacerbate the illness
Revision Requirements
Repeat/Revision of bariatric surgery: may be considered medically necessary (when specifically included as a benefit or covered service in the member’s benefit plan, summary plan description or contract) only when ALL of the following criteria are met:
- Original surgery was considered a covered benefit of the member’s current plan, AND the repeat/revision of bariatric surgery is a covered benefit of the member’s current plan
- For the original procedure, patient met all the screening criteria, including BMI requirements
- The patient has been compliant with a prescribed nutrition and exercise program following the original surgery
- Significant complications or technical failure (e.g., breakdown of gastric pouch, slippage, breakage or erosion of gastric band, bowel obstruction, staple line failure, etc.) of the bariatric surgery has occurred that requires take down or revision of the original procedure that could only be addressed surgically
- Patient is requesting reinstitution of an acceptable bariatric surgical modality
- NOTE: A Roux-en-Y procedure following a previously approved vertical banded gastroplasty or laparoscopic adjustable banded gastroplasty is not eligible for coverage for patients who have been substantially noncompliant with a prescribed nutrition and exercise program following the original procedure
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.
Contact Blue Cross Blue Shield Illinois to Ask About Bariatric Surgery
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 Illinois 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 Illinois 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:
- Gastric Sleeve
- Gastric Bypass
- Lap-Band
Please see below for the procedures Blue Cross Blue Shield Illinois covers, might cover under certain circumstances, and those that are not covered under any circumstances:
Procedures That ARE Covered
Procedures That MIGHT BE Covered
Biliopancreatic bypass WITH duodenal switch – may be considered medically necessary as a surgical treatment option for morbidly obese patients with BMI of 50 kg/m² or greater who meet the other eligibility criteria for surgery
The following procedures MIGHT BE covered by Blue Cross Blue Shield Illinois:
- Revision Surgery (either Lap-Band Revision or Gastric Bypass Revision)
Procedures That Are NOT Covered
The following procedures are NOT covered by Blue Cross Blue Shield Illinois:
- Gastric Balloon
- AspireAssist
- Vertical Banded Gastroplasty
- Mini Gastric Bypass Surgery
- Biliopancreatic bypass without duodenal switch
- Long limb gastric bypass procedures (e.g., >150 cm)
- Two-stage bariatric surgery procedures (e.g., sleeve gastrectomy as initial procedure followed by biliopancreatic diversion at a later time)
- Endoluminal procedures including but not limited to:
- Natural Orifice Transluminal Endoscopic Surgery (NOTES™)
- Transoral gastroplasty (TOGA)
- Endoscopic procedures (e.g., insertion of the StomaphyX™ device) including but not limited to sclerotherapy of the stoma
- Transoral ROSE procedure (Restorative Obesity Surgery)
SECTION SUMMARY:
- General Appeal Instructions
- Appeal Details Specific to Blue Cross Blue Shield Illinois
If Blue Cross Blue Shield Illinois 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 Illinois to learn how to proceed.
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:
