Blue Shield of CA Weight Loss Surgery – How to Avoid a Denial

Your Blue Shield of California weight loss surgery insurance coverage depends on several factors, all of which are reviewed below.

First, try our insurance tool to quickly check your insurance 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
Blue Shield California Weight Loss Surgery

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 Shield California for bariatric surgery in the United States, you must meet the following criteria:

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

    • BMI 35 – 39.9 AND one of the following
      • Type 2 Diabetes Mellitus
      • Hypertension
      • Coronary Artery Disease
      • Obstructive Sleep Apnea

    Use this BMI Calculator to check your body mass index…

  3. Continued obesity despite trials of weight loss through lifestyle changes, diet modification and exercise evidenced by all of the following:
    • Documentation of prior weight loss attempts without successful long-term reduction
    • Documentation of active participation in a non-surgical weight reduction program supervised by a registered dietician, healthcare provider (e.g., physician, nurse practitioner), or an organized weight reduction program (e.g., Weight Watchers™, Jenny Craig™), for at least six consecutive months occurring within the last 18 months prior to the request for bariatric surgery
    • Monthly documentation of all of the following weight reduction program components:
      • Weight
      • Dietary regimen, which may include medical nutrition therapy (e.g., MediFast™ and OptiFast™) or a recognized commercial diet-based weight loss program (e.g., Weight Watchers™, Jenny Craig™, etc)
      • Physical exercise unless medically contraindicated
      • Behavior modification or behavioral health interventions

    A Note About Weight Reduction Programs

    A physician’s summary letter is not sufficient documentation of active patient participation in a non-surgical weight reduction program. Documentation must include medical records and/or diet or weight-loss logs, and assessment of the patient’s progress throughout the programs course.

  4. Bariatric surgical consultation and recommendation by a trained and experienced bariatric surgeon associated with an institution that supports a comprehensive bariatric surgery program, which includes all of the following:
    • Psychological evaluation and clearance for bariatric surgery
    • Nutritional evaluation
    • Long-term monitoring and follow-up post surgery

Adolescents Requirements

  • BMI > 40.0 with at least one significant obesity-related disease complication which has failed to be controlled with medical management including, but not limited to:
    • Type 2 Diabetes Mellitus
    • Hypertension
    • Heart disease
    • Obstructive Sleep Apnea
    • BMI >/= 50.0 kg/m2 with less severe obesity-related complications

Revision Requirements

  • Revision surgery is considered medically necessary to address perioperative or late complications of a bariatric procedure. These include, but are not limited to:
    • Staple-line failure
    • Obstruction
    • Stricture Non-absorption resulting in hypoglycemia or malnutrition
    • Weight loss of 20% or more below ideal body weight
  • Revision of a primary bariatric procedure that has failed due to dilation of the gastric pouch (documented by upper gastrointestinal examination or endoscopy) is considered medically necessary when all of the following are met:
    • The initial procedure was successful in inducing weight loss prior to pouch dilation
    • The patient has been compliant with a prescribed nutrition and exercise program
    • The patient still meets BMI criteria for bariatric surgery

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 Shield California to Ask About Bariatric Surgery

02.

Coverage by Plan Type

SECTION SUMMARY:

  • Coverage Through Your Employer
  • Individual & Family Plans
  • Medicare
Blue Shield California Weight Loss Surgery

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 Shield California 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 Shield California 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.

03.

Covered Weight Loss Procedures

SECTION SUMMARY:

  • Gastric Sleeve
  • Gastric Bypass
  • Lap-Band
  • Vertical Banded Gastroplasty
Blue Shield California Weight Loss Surgery

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

Procedures That ARE Covered

Procedures That MIGHT BE Covered

The following procedures MIGHT BE covered by Blue Shield California:

Procedures That Are NOT Covered

The following procedures are NOT covered by Blue Shield California:

04.

Appealing a Denial

SECTION SUMMARY:

  • General Appeal Instructions
  • Appeal Details Specific to Blue Shield California
Blue Shield California Weight Loss Surgery

If Blue Shield California 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 Shield California 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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