Your Excellus Blue Cross Blue Shield 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
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- 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 policiy 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 Excellus Blue Cross Blue Shield for bariatric surgery in the United States, you must meet the following criteria:
- Be age 18 years of age or older
- Diagnosis of Morbid obesity, defined as
- a Body Mass Index (BMI) greater than 40
- BMI 35 – 39.9 AND one of the following
- Hypertensive cardiovascular disease
- Coronary heart disease
- Pulmonary hypoventilation
- Sleep apnea
- Degenerative arthritis of weight-bearing joints or other weight related arthropathies
- Metabolic syndrome
Use this BMI Calculator to check your body mass index…
- There must be written evidence of a weight loss history, either by the bariatric surgeon, primary care physician or nutritionist. This documentation should include the name of the weight loss program, length of participation in the program and any weight loss achieved. At least one program must have been a supervised weight loss program
- Weight loss attempts need not be continuous, but a minimum total of six months is required
- If the patient has had no previous attempts at medical weight loss, participation for a minimum of six months in a preoperative bariatric surgery weight loss program is required
- If past prior attempts of weight loss are remote (greater than 5 years), then the patient is required to participate, for a minimum of six months in a preoperative bariatric surgery weight loss programd
Laparoscopic Adjustable Gastric Banding
Based upon our criteria and assessment of peer-reviewed literature, the surgical management of morbid obesity by laparoscopic adjustable gastric banding is considered medically appropriate in the following circumstances:
- The patient must meet all the requirements listed above in Policy Statement I, A-H
- The dietary history does not include a large consumption of high caloric liquids (e.g., milk shakes) or sweets
- The patient has no significant history of esophageal or gastric disease (please note contraindications to adjustable gastric banding listed in the rationale section)
- The patient must participate in a pre-operative bariatric program that requires a 5% weight loss to demonstrate commitment to behavioral and dietary changes. The 5% weight loss will be measured from the date of the patient’s initial visit to the bariatric surgeon to the date of the request for pre-authorization of the adjustable gastric banding procedure
A revision or removal of a laparoscopic adjustable gastric band is considered medically necessary for complications or for a technical failure. Examples of complications and technical failures that may warrant a revision, removal, or conversion to another procedure include:
- Band slippage
- Band erosion
- Esophageal dilation
- Displaced band
- Port dislocation
- Too tight a band creating food passage problems
- Band intolerance (e.g., pain, vomiting)
- Port and/or catheter leakage
A revision or conversion to another medically appropriate procedure because of unsatisfactory weight loss due to technical failure of the primary bariatric procedure such as pouch dilation or an initial pouch size that is too large is considered medically appropriate if there is documentation regarding all of the following submitted with the request:
- Primary procedure was initially successful in inducing weight loss
- Patient has remained compliant to the prescribed nutrition and exercise program
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.
Excellus Blue Cross Blue Shield Contact Information and Full Medical Policy on Bariatric Surgery
- Coverage Through Your Employer
- Individual & Family Plans
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.
Excellus Blue Cross Blue Shield does cover weight loss surgery, but your specific policy must include it in order for you get it covered.
Following are a list of Excellus Blue Cross Blue Shield 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)
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Rhode Island
- South Dakota
- West Virginia
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.
- Gastric Sleeve
- Gastric Bypass
- Duodenal Switch
Please see below for the procedures Excellus Blue Cross Blue Shield 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 Excellus Blue Cross Blue Shield:
Procedures That Are NOT Covered
The following procedures are NOT covered by Excellus Blue Cross Blue Shield:
- Gastric Balloon
- Vertical Banded Gastroplasty
- Mini Gastric Bypass Surgery
- Single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S)
- Transoral gastroplasty or endoscopic/endoluminal procedures:
- Restorative Obesity Surgery
- Endoluminal or ROSE
- TOGA System
- Overstitch device
- General Appeal Instructions
- Appeal Details Specific to Excellus Blue Cross Blue Shield
If Excellus Blue Cross Blue Shield denies your weight loss surgery claim and you think it should be covered, consider filing an appeal.
- 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: