BCBS of North Carolina Weight Loss Surgery – How to Avoid a Denial

Your Blue Cross Blue Shield North Carolina 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.

Adults Only

In order to be approved by Blue Cross Blue Shield North Carolina for bariatric surgery in the United States, you must meet the following criteria:

  1. Diagnosis of Morbid obesity, defined as
  2. Or

    • have a BMI > 35 associated with at least one or more of the fol lowing problems which are generally expected to be improved, curtailed or reversed by surgical treatment:
      • The obesity interferes with daily function to the extent that performance is severely curtailed (i.e., impending job loss or job loss with documented disability)
      • The obesity causes incapacitating pain and limitation of motion in any weight-bearing joint or the lumbosacral spine documented by physical examination in association with radiologic findings showing degenerative osteoarthritis
      • There is significant respiratory insufficiency as evidenced by pCO2 > 50 mmHg, hypoxemia at rest, as evidenced by pO2 < 55 mmHg on room air; FEV 1/FVC < 65%, or DLCO < 60% (e.g., Obesity Hypoventilation Syndrome)
      • Clinically significant obstructive sleep apnea (i.e., Patient meets criteria for treatment of obstructive sleep apnea set forth in a separate policy, titled Sleep Apnea : Diagnosis and Medical Management
      • Type 2 diabetes mellitus
      • Documented coronary artery disease
      • Cardiomyopathy
      • Heart failure
      • Gastroesophageal reflux disease with secondary asthma or erosive esophagitis not controlled despite maximum dosages of proton pump inhibitors
      • Pseudotumor cerebri
      • Patient has at least one of the following:
        • Medically refractory hypertension (blood pressure > 140 mmHg systolic and/or > 90 mmHg diastolic measured with appropriate size cuff) that has not responded to medical management including at least two (2) anti-hypertensive drugs at maximum tolerated dosages
        • First degree relative with premature (age < 50) cardiovascular disease
        • Hypercholesterolemia > 240 mg/dL or hypertriglyceridemia > 400 mg/dL or low density lipoprotein (LDL) > 160 mg/dL or high density lipoprotein (HDL) < 40 mg/dL ; despite appropriate medical therapy defined as at least one appropriate drug at maximum dosage
        • Metabolic syndrome
        • Pulmonary hypertension
      • The patient has no specifically correctable cause for the obesity, e.g., an endocrine disorder
      • A thorough evaluation has been documented to assess the patient’s suitability for surgery and their ability to comply with lifelong follow up
      • Surgery for morbid obesity is eligible for coverage when it is part of a comprehensive pre-surgical, surgical and post-surgical program

Use this BMI Calculator to check your body mass index…

Adults & Adolescents

A thorough preoperative evaluation for surgery for morbid obesity must include all of the following:

  1. Evaluation of the patient’s understanding of the procedure to be performed, including the procedure’s risks and benefits, length of stay in the hospital, behavioral changes required prior to and after the surgical procedure (including dietary and exercise requirements), follow up requirements with the performing surgeon, and anticipated psychological changes
  2. Evaluation of the patient’s family/caregivers support and understanding of the information in #1
  3. Within 12 months prior to surgery, a thorough nutritional evaluation by a physician, registered dietician, or other licensed professional experienced in the issues of bariatric surgery, who has had a meaningful conversation with the individual regarding the dietary and lifestyle changes required to ensure a successful outcome over time. Nutritional assessment must follow American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines. Pre-operative assessment must document that the patient has a good understanding of the diet and nutritional changes that are associated with bariatric surgery and has the capacity to comply with these changes. Per the ASMBS guidelines, “…it is essential to determine any preexisting nutritional deficiencies, develop appropriate dietary interventions for correction, and create a plan for postoperative dietary intake that will enhance the likelihood of success. Not only should the practitioner review the standard assessment components (i.e., medical co – morbidities, weight history, laboratory values, and nutritional intake ), it is also important to evaluate other issues that could affect nutrient status, including readiness for change, realistic goal setting, general nutrition knowledge, as well as behavioral, cultural, psychosocial, and economic issues”
  4. Evaluation by a licensed psychologist, psychiatrist or licensed clinical social worker that documents the absence of significant psychopathology that can limit the patient’s understanding of the procedure or the ability to comply with medical/surgical recommendations and to adhere to required lifestyle modifications and follow up/ social support. Documentation from that evaluation must include the patient’s suitability for the proposed bariatric surgery and the lifetime commitment required for a successful outcome
  5. Appropriate medical workup may include a chest x-ray, upper gastrointestinal series, endoscopy, appropriate pre-op labs and ECG. A complete physical examination by the attending surgeon and an assessment of thyroid levels is required. If the patient has comorbid conditions (e.g. diabetes or cardiovascular disease) the patient must be capable of undergoing the procedure
  6. Anesthesia clearance for surgery

Blue Cross Blue Shield North Carolina requires the first five criteria above to be met before seeking prior plan approval for adults and adolescents; the sixth must be met prior to surgery.

Surgical procedures must be performed at a facility capable of providing gastrointestinal and biliary surgery (preferably JCAHO accredited), AND that has equipment and staff capable of managing a morbidly obese patient (appropriate instruments, beds, lifts, monitoring equipment) AND that can manage short and long term complications of surgery for morbid obesity.

The performing surgeon must be qualified and experienced in performing the procedure to be undertaken.

Follow up programs must include regular follow up for at least five years , including postoperative nutrition follow-up.

Significant weight loss following surgery for morbid obesity can lead to redundant skin and fat folds in varied anatomic locations (e.g., breasts, medial upper arms, and medial thighs, lower abdominal area also called “abdominal apron” or pannus). Surgical removal of redundant skin and f at folds is generally considered cosmetic and is not covered. Coverage may be considered for panniculectomy in patients who meet criteria specified in separate policy, Abdominoplasty, Panniculectomy, and Lipectomy.

Limited evidence is available on bariatric surgery in patients with a BMI of less than 35. Case series report a high rate of remission of diabetes in undergoing gastric bypass surgery; however, bariatric surgery for diabetes in patients with a BMI less than 35 is not currently considered standard of care and is not supported in current specialty society guidelines. For patients without diabetes, there is limited evidence on outcomes of surgery and no evidence that health outcomes are improved.

Patients with a BMI greater than or equal to 50 kg/m 2 need a bariatric procedure to achieve greater weight loss. Thus, use of adjustable gastric banding, which results in less weight loss, should be most useful as one of the procedures used for patients with BMI less than 50 kg/m 2. Malabsorptive procedures, although they produce more dramatic weight loss, potentially result in nutritional complications, and the risks and benefits of these procedures must be carefully weighed in light of the treatment goals for each patient.

Prior to consideration of a second bariatric procedure , patients who have undergone adjustable gastric banding must demonstrate that appropriate band adjustments in conjunction with regular post – operative visits and nutritional compliance has failed to result in adequate weight loss.

Adolescents Only

Bariatric surgery in adolescents may be considered medically necessary according to the same weight-based criteria used for adults, but greater consideration should be given to psychosocial and informed consent issues. In addition, any devices used for bariatric surgery must be in accordance with the FDA-approved indications for use.

In addition to the weight-based criteria, there is greater emphasis on issues of developmental maturity, psychosocial status, and informed consent for adolescent patients. All guidelines mention these issues, but recommendations are not uniform for addressing them.

The Endocrine Society published recommendations for the following for prevention and treatment of pediatric obesity in 2008. These guidelines contained the following recommendations for bariatric surgery:

  • The child has attained Tanner 4 or 5 pubertal development and final or near – final adult height
  • The child has a BMI 50 kg/m 2 or has BMI above 40kg/m 2 and significant, severe comorbidities
  • Severe obesity and comorbidities persist despite a formal program of lifestyle modification, with or without a trial of pharmacotherapy
  • Psychological evaluation confirms the stability and competence of the family unit
  • There is access to an experienced surgeon in a medical center employing a team capable of long-term follow-up of the metabolic and psychosocial needs of the patient and family, and the institution is either participating in a study of the outcome of bariatric surgery or sharing data
  • The patient demonstrates the ability to adhere to the principles of healthy dietary and activity habits
  • Bariatric surgery is not recommended for preadolescent children, for pregnant or breast-feeding adolescents, and for those planning to become pregnant within 2 years of surgery; for any patient who has not mastered the principles of healthy dietary and activity habits; for any patient with an unresolved eating disorder, untreated psychiatric disorder, or Prader-Willi syndrome

Revision Requirements

Revision surgery to address perioperative or late complications of the original bariatric procedure is considered medically necessary. These include, but are not limited to, staple-line failure, obstruction, stricture, erosion, non-absorption resulting in hypoglycemia or malnutrition, weight loss of 20% or more below ideal body weight, band herniation, and band slippage that cannot be corrected with manipulation or adjustments.

Revision of a primary bariatric procedure that has failed due to dilation of the gastric pouch or dilation proximal to an adjustable gastric band or other restrictive procedure (documented by upper gastrointestinal examination or endoscopy) is considered medically necessary if the initial procedure was successful in inducing weight loss prior to dilation, and the patient has been compliant with a prescribed nutrition and exercise program.

Repeat surgical procedures for revision or conversion to another surgical procedure (that is also considered medically necessary within this document) for inadequate weight loss, (that is, unrelated to a surgical complication of a prior procedure) are considered medically necessary when all the following criteria are met:

  • The individual continues to meet all the medical necessity criteria for bariatric surgery, including current pre-operative nutritional assessment
  • There is documentation of compliance with the previously prescribed postoperative dietary and exercise program
  • Weight loss following the original surgery is less than 50% of pre-operative excess body weight and weight remains at least 30% over ideal body weight

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 North Carolina 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 North Carolina 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 North Carolina 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
  • Duodenal Switch

Please see below for the procedures Blue Cross Blue Shield North Carolina covers, might cover under certain circumstances, and those that are not covered under any circumstances:

Procedures That ARE Covered

Procedures That MIGHT BE Covered

Long limb Roux-en-Y, involving more than 150 cm of the small intestine, only when performed as a revision procedure after a standard gastric bypass has failed to resolve comorbidities and/or result in satisfactory weight loss as defined by the National Heart Lung and Blood Institute.

The following procedures MIGHT BE covered by Blue Cross Blue Shield North Carolina:

Procedures That Are NOT Covered

The following procedures are NOT covered by Blue Cross Blue Shield North Carolina:

  • Gastric Balloon
  • vBloc Therapy
  • AspireAssist
  • Vertical Banded Gastroplasty
  • Mini Gastric Bypass Surgery
  • Jejunoileal bypass – any surgical procedure that shunts ingested food from the jejunum into the ileum thus bypassing a majority of the small intestine
  • Gastric wrapping – a surgical procedure in which the stomach is folded over on itself and a full stomach wrap (polypropylene mesh) is applied. The outcome is to limit gastric volume
  • Adjustable Gastric Banding in non-adult patients (patients under 18 years of age)
  • Jejunocolostomy – a surgical procedure that entails anastomosis of the end of the jejunum to the mid-transverse colon thus creating a short bowel syndrome
  • Gastric bypass using a Billroth II type of anastomosis, popularized as the mini-gastric bypass
  • Endoscopic procedures (e.g., insertion of the StomaphyX device endoluminal fastener and delivery system) as a primary bariatric procedure or as a revision procedure, i.e., to treat weight gain after bariatric surgery to remedy large gastric stoma or large gastric pouches
  • Laparoscopic gastric plication (laparoscopic greater curvature plication [LGCP]) with or without gastric banding
  • Two-stage bariatric surgery procedures (e.g., sleeve gastrectomy as initial procedure followed by biliopancreatic diversion at a later time)
  • Long limb Roux-en-Y, involving more than 150 cm of the small intestine , when performed as a primary bariatric procedure
  • As a cure for type 2 diabetes mellitus , when patients do not meet BMI criteria for bariatric surgery
  • For patients with a BMI less than 35
04.

Appealing a Denial

SECTION SUMMARY:

  • General Appeal Instructions
  • Appeal Details Specific to Blue Cross Blue Shield North Carolina

If Blue Cross Blue Shield North Carolina 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 North Carolina 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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