Your Regence 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 Regence Blue Cross Blue Shield for bariatric surgery in the United States, you must meet the following criteria:
- Age greater than or equal to 18 years
- Diagnosis of Morbid obesity, defined as
- a Body Mass Index (BMI) greater than 40
- BMI greater than or equal to 35 either with a diagnosis of type 2 diabetes mellitus or with at least two of the following comorbid conditions which have not responded to medical management and which are generally expected to improve as a result of obesity surgical treatment:
- Coronary heart disease
- Sleep apnea
Use this BMI Calculator to check your body mass index…
- Occur during at least 6 consecutive months within the 24 months prior to the request for surgery
- Include at least three visits for medical supervision, occurring at intervals of no longer than four months apart (e.g., at the start, middle and end of the 6 month weight loss program)
- Be provided by an MD, DO, NP, PA or a registered dietitian under the supervision of an MD, DO, NP, or PA
- Include assessment and counseling concerning weight, diet, exercise, and behavior modification
- Evaluation by a licensed psychologist, psychiatrist, or LCSW documents the absence of significant psychopathology that can limit an individual’s understanding of the procedure or ability to comply with medical/surgical recommendations (e.g., active substance abuse, eating disorders, schizophrenia, borderline personality disorder, uncontrolled depression)
- Clinical documentation, by either a psychological or surgical evaluation, of willingness to comply with preoperative and postoperative treatment plan
Reoperation for the following documented significant complications of a bariatric procedure may be considered medically necessary:
- Band erosion or migration (slippage), that cannot be corrected with manipulation or adjustment
- Staple-line failure
- Weight loss to 80% or less of ideal body weight
Reoperation with removal of adjustable gastric band and conversion to a gastric bypass using a Roux-en-Y anastomosis or sleeve gastrectomy may be considered medically necessary AND the criteria listed above are met.
Reoperation which does not meet the above criteria is considered not medically necessary, including but not limited to reoperation for the following indications:
- Early satiety
- Patient dissatisfaction
- Gastro-esophageal reflux disease (GERD)
- Conversion of a prior procedure to a different procedure (e.g., laparoscopic adjustable banding to gastric bypass)
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.
Regence Blue Cross Blue Shield Contact Information and Full Medical Policy on Bariatric Surgery
- By Phone:
- Oregon: 1 (888) 675-6570
- Utah: 1 (888) 231-8424
- Contact Regence Blue Cross Blue Shield
- Full Bariatric Surgery Medical Policy for Regence Blue Cross Blue Shield
- 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.
Regence 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 Regence 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
Please see below for the procedures Regence 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 Regence Blue Cross Blue Shield:
Procedures That Are NOT Covered
The following procedures are NOT covered by Regence Blue Cross Blue Shield:
- Duodenal Switch
- Gastric Balloon
- Vertical Banded Gastroplasty
- Mini Gastric Bypass Surgery
- Distal gastric bypass (long limb gastric bypass, i.e., >150 cm)
- Biliopancreatic bypass (i.e., the Scopinaro procedure)
- Two-stage bariatric surgery procedures (e.g., sleeve gastrectomy followed by gastric bypass, sleeve gastrectomy followed by biliopancreatic diversion)
- Adjustable gastric banding with existing gastric bypass or sleeve gastrectomy
- Endoscopic procedures including but not limited to:
- StomaphyX™ (EndoGastric Solutions, Inc)
- ROSE procedure (Restorative Obesity Surgery, Endoscopic ™)
- EndoCinch™ (Bard)
- EndoSurgical Operating System™ (EOS) (USGI Medical, Inc)
- Sclerotherapy of stoma
- General Appeal Instructions
- Appeal Details Specific to Regence Blue Cross Blue Shield
If Regence 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: