BC of NE Pennsylvania Weight Loss Surgery – How to Avoid a Denial

Your Blue Cross of Northeastern Pennsylvania 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 of Northeastern Pennsylvania for bariatric surgery in the United States, you must meet the following criteria:

  1. The member must be at least 18 years of age
  2. The member’s condition of morbid obesity must be documented to be of at least 5 years’ duration and meets either of the following criteria:
  3. Or

    • BMI 35 – 39.9 AND one of the following

    Use this BMI Calculator to check your body mass index…

  4. A letter of support for the surgery must be submitted from the primary care physician or physician currently providing care for the member, and familiar with his/her health history, health risks, and current health status including issues related to obesity
  5. Written documentation must be submitted showing no significant lung, cardiac, liver, kidney, or gastrointestinal disease present that unduly increases operative and post-operative risks (unstable or poorly controlled angina, hepatic cirrhosis, severe renal insufficiency, nephrotic syndrome, inflammatory bowel disease, malabsorption syndromes)
  6. Documentation must be submitted showing that metabolic causes for obesity (e.g., adrenal or thyroid disorders) have been ruled out
  7. Patients must be screened by a licensed psychologist, psychiatrist or licensed clinical social worker familiar with the requirements of Bariatric Surgery, to identify psychopathology (examples include but are not limited to: schizophrenia, obsessive-compulsive disorder, borderline personality disorder, bipolar disorder, severe depression, alcoholism, substance abuse, or eating disorders.) which might interfere with their ability to comply with the rigorous pre-and post-operative regimens required for success
    • All patients who have had a psychiatric hospitalization and who are maintained on psychotropic medications must have a clearance from a licensed psychiatrist prior to surgery. Written documentation of this evaluation and psychological assessment of appropriateness for surgery must be provided
  8. Gastric Bypass surgery may affect the absorption of medication that might lead to irregular blood levels of medication. Where drug level maintenance is critical, bypass surgery may be contraindicated

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.

Blue Cross of Northeastern Pennsylvania Contact Information and Full Medical Policy on 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 of Northeastern Pennsylvania 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 of Northeastern Pennsylvania 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 of Northeastern Pennsylvania covers, might cover under certain circumstances, and those that are not covered under any circumstances:

Procedures That ARE Covered

Other Procedures Covered by Blue Cross of Northeastern Pennsylvania During Weight Loss Surgery

Routine cholecystectomy (procedure to remove gallbladder) when performed at the same time as elective surgery for the treatment of morbid obesity (due to the high incidence of gallbladder disease associated with this surgery).

Procedures That Are NOT Covered

The following procedures are NOT covered by Blue Cross of Northeastern Pennsylvania:

  • Gastric Balloon
  • AspireAssist
  • Vertical Banded Gastroplasty
  • Mini Gastric Bypass Surgery
  • Biliopancreatic Bypass without duodenal switch
  • Long Limb Gastric Bypass procedure (i.e., > 150 cm)
  • Two-stage bariatric surgery procedures (e.g., sleeve gastrectomy as initial procedure followed by biliopancreatic diversion at a later time)
  • Endoscopic procedures (e.g., insertion of the StomaphyX™ device) 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)
  • Any morbid obesity surgical procedure when performed for patients with a BMI less than 35 kg/m²
04.

Appealing a Denial

SECTION SUMMARY:

  • General Appeal Instructions
  • Appeal Details Specific to Blue Cross of Northeastern Pennsylvania

If Blue Cross of Northeastern Pennsylvania 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 of Northeastern Pennsylvania 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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