Regence BCBS Weight Loss Surgery – How to Avoid a Denial

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

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 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:

  1. Age greater than or equal to 18 years
  2. Diagnosis of Morbid obesity, defined as
  3. Or

    • 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:
      • Hypertension
      • Dyslipidemia
      • Coronary heart disease
      • Sleep apnea

    Use this BMI Calculator to check your body mass index…

  4. Documentation of active participation for at least six months in a structured, medically supervised nonsurgical weight reduction program. A comprehensive commercial weight loss program is an acceptable program component, but it must be approved and monitored under the supervision of the healthcare practitioner providing medical oversight. Comprehensive weight loss programs generally address diet, exercise and behavior modification (e.g. Weight Watchers)
  5. Documentation from the clinical medical records must indicate that the structured medical supervision meets all of the following criteria:
    • 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
  6. Preoperative evaluation to include both of the following:
    • 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

Revision Requirements

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
  • Leak
  • Obstruction
  • 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
  • Nausea
  • 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

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.

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:

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

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:

04.

Appealing a Denial

SECTION SUMMARY:

  • 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.

Our Health Insurance Appeals page will get you started, then head over to the Disputes & Appeals page for Regence Blue Cross Blue Shield 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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