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

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

  1. Coverage Requirements
  2. Coverage Plans
  3. Covered Procedures
  4. Appealing a Denial
  5. Find a Weight Loss Surgeon
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01.

Coverage Requirements

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:

  1. Growth is completed (generally, growth is considered completed by 18 years of age)
  2. Diagnosis of Morbid obesity, defined as
  3. Or

    • 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

    Use this BMI Calculator to check your body mass index…

  4. 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:
      1. Nutrition program, which may include a very low calorie diet or a recognized commercial diet-based weight loss program
      2. Behavior modification or behavioral health interventions
      3. Counseling and instruction on exercise and increased physical activity
      4. 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:
      1. The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations
      2. The absence of any psychological comorbidity that could contribute to weight mismanagement or a diagnosed eating disorder
      3. The patient’s willingness to comply with preoperative and postoperative treatment plans

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

02.

Coverage by Plan Type

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:

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:

    • 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:

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

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03.

Covered Weight Loss Procedures

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 switchmay 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:

Procedures That Are NOT Covered

The following procedures are NOT covered by Blue Cross Blue Shield Illinois:

  • Gastric Balloon
  • vBloc Therapy
  • 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)
04.

Appealing a Denial

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.

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:

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