Hi, I found this while looking up more information about the insurance coverage for GBS.
Insurance Coverage for Weight Loss Surgery
Over 90% of our clients are able to use their private insurance to cover their ariatric surgery. After the 1991 National Institute of Health Consensus conference, the federal government mandated coverage for all federal mployees. This opened the door for most insurance carriers to investigate offering bariatric surgery coverage for their plan holders. In 2006, The Center for Medicare Services Administration standardized coverage for bariatric surgery for all Medicare and Medicare recipients.
With the increasing awareness of the benefits of bariatric surgery, the costs to the insurance providers have increased sharply. Many plans now have specific requirements that have to be met to allow access to coverage for surgery. It is worthwhile to note that bariatric surgery is the ONLY area of medicine to be subjected to this kind of scrutiny when predetermining coverage. Our staff has many years of experience working with the insurance companies and enjoy a high success rate of approvals for our clients.
Below is a brief listing of some of the larger insurance companies and their coverage criteria:
Universal Treatment Requirements:
NIH criteria for surgical treatment of obesity:
BMI greater or equal to 40 (80-100lbs overweight)
BMI greater or equal to 35 with presence of severe co-morbid condition such as diabetes, hypertension, sleep apnea, or heart disease.
If you have a BMI below 35, your insurance will not provide coverage for surgery. However you may be considered for surgery on a self-pay basis.
General Insurance Requests – As of July 2, 2008
Aetna: Per Clinical Policy Bulletin 0157, all patients require 2 years documented medical history of morbid obesity, 3 months physician supervised non-surgical diet, exercise and behavior modification treatment and a psych evaluation if medically indicated.
Anthem Blue Cross: Per Clinical Policy Bulletin SURG.00024 insurance requires Attachment A to be filled out which requires psych and one diet consult. This is faxed with the LOMN to 317-287-7071 or 7400.
Blue Cross Federal: Pt must have BMI over 40 or BMI 35-40 with treated, uncontrolled co-morbid condition.
Blue Cross of Alabama: Per Policy Bulletin 053 insurance requires 6 months diet (supervised by non-bariatric surgeon), three years medically documented morbid obesity and H & P by bariatric surgeon. They will accept Weight Watchers, LA Weight Loss, Jenny Craig etc. with physician supervision and documentation.
Blue Cross of Arkansas: Per Policy Bulletin 1998118 insurance requires BMI over 36 and failed structured weight loss program.
Blue Cross of California: (mandated coverage) Per Policy Bulletin SURG.00024 insurance requires one diet consult with history of previous attempts, psych and compliance letter from patient and treatment plan.
Blue Cross of Delaware: Per fax back questionnaire, insurance requires LOMN, cardiac, pulmonary and psych clearance and sleep apnea work-up.
Blue Cross of Florida: Per Policy Bulletin 02-40000-10 insurance requires five-year history, 6 month diet, psych evaluation, and TSH showing no endocrine disorders. Sleeve is covered.
Blue Cross of Georgia: Per Policy Bulletin SURG.00024 insurance requires one diet consult with history of previous attempts, psych and compliance letter from patient and treatment plan.
Blue Cross of Illinois: Per Policy Bulletin SUR716.003 insurance requires five-year history, 6 month diet, psych evaluation and willingness to comply letter.
Blue Cross of Massachusetts: (mandated coverage) Per Policy Bulletin 379 insurance requires one diet consult with history of previous attempts. Fax info to 888-641-5330.
Blue Cross of Michigan: Per Policy Bulletin – The Record of March 2005, insurance requires medically supervised 12 month diet failure, PCP clearance and psych evaluation.
Blue Cross of Minnesota: Per Policy Bulletin IV-19 insurance requires two year history of morbid obesity, 6 month diet failure, psych evaluation and compliance letter – SLEEVE may be considered with BMI >50 and severe co-morbid conditions.
Blue Cross of Mississippi: Per Employee Access Policy Bulletin insurance requires five-year history of morbid obesity, documentation of failed diet attempts and TSH – NO LAP BAND.
Blue Cross of Nebraska: Per Policy Bulletin 1.23, insurance requires five-year history, no treatable medical cause for obesity and over age 16.
Blue Cross of New Mexico: Per Policy Bulletin SUR716.003 insurance requires five-year history, 6 month diet, psych evaluation and willingness to comply letter.
Blue Cross of North Carolina: Per medical policy bulletin SUR6710 insurance requires five-year history, psych, PCP clearance with TSH and diet consult.
Blue Cross of Oklahoma: Per Policy Bulletin SUR716.003 insurance requires five-year history, 6 month diet, psych evaluation and willingness to comply letter.
Blue Cross of Tennessee: Per medical policy insurance requires completion f the Pre-Bariatric Evaluation Tool, requests documentation of specific dates of diets, length of diets with successes and failures for past two years, five year history and psych evaluation.
Blue Cross of Texas: Per Policy Bulletin SUR716.003 insurance requires five-year history, 6 month diet, psych evaluation and willingness to comply letter.
Blue Shield of California: (mandated coverage) Per Policy Bulletin insurance requires medical/surgical evaluation and clearance, psych evaluation and one diet consult.
Champ VA: Per Policy Bulletin 38 CFR 17.270(a) and 17.272(a)(22) with Related Authority 32 CFR 199.4(e)(15) insurance requires BMI over 40, BMI over 35 with an associated co-morbid or revision due to complications.
Cigna: Per Policy Bulletin 0051 insurance requires 6 month diet supervised by PCP or physician other than a bariatric surgeon, medical evaluation by PCP, psych evaluation and two year history.
Empire Blue Cross: Per Policy Bulletin SURG.00024 insurance requires diet consult, exercise consult, TSH, psych evaluation and attendance at support groups.
Excellus Blue Cross: Per Policy Bulletin 7.01.29 insurance requires 5-year history, 6 month diet, TSH and psych evaluation.
First Health: Per faxed policy insurance requires 3 month multi-disciplinary diet approach, psych evaluation, cardiac evaluation, pulmonary evaluation and post-op program.
Great West: Per Policy Bulletin 95.204.06103 insurance requires five-year history, 6 months medically supervised diet, PCP clearance with TSH and psych evaluation.
Health Scope Benefits: Per faxed policy insurance requires initial history and physical exam with office notes and any lab work done
Highmark Blue Cross: Per Policy Bulletin G-24 insurance requires physician supervised 6 month diet and exercise program and psych evaluation.
Horizon Blue Cross: Per Policy Bulletin 022 insurance requires five-year history of morbid obesity, 6 month diet and exercise program and psych evaluation.
Humana: Per Policy Bulletin insurance requires 6 month medically supervised diet, PCP clearance and psych evaluation.
Independence Blue Cross: Per Policy Bulletin 11.03.02b insurance requires medical clearance, psych clearance and 3 month multidisciplinary diet, exercise and behavior modification.
Medicare: Per Policy Bulletin S-131A insurance requires BMI of >35 with at least one co-morbid condition, minimum two year history of morbid obesity, 6 month PCP diet or 3 month multi-disciplinary diet, exercise and behavior modification program with neither supervised by the surgeon and psych evaluation.
Pacificare – Secure Horizons: Per Utilization Management at Pacificare, this is a general exclusion on the policy but should be submitted with LOMN, PCP, pulmonary, cardiac and psychiatric clearance along with three year history of diets tried and outcomes. Fax to 800-438-5470.
Premera Blue Cross: Per Policy Bulletin CP.MP.
PR.7.01.516*, only requires form 14784 faxed in with letter of medical necessity and after care explanation letter.
Principal Financial Group: Per fax transmission insurance requires three-year history, 6 month diet supervised by physician other than surgeon and psych evaluation.
Regence Blue Shield: Per Policy Bulletin 58 insurance requires five-year history, 12 month diet, psych and documentation of willingness to comply.
Unicare: Per Policy Bulletin SURG.00024 insurance requires one in depth diet consult and psych evaluation.
United Health Care – THR: Pt has a $4000 bariatric co-pay and must attend five months of Healthy Weight – NO LAP BAND.
Wellmark: Per Policy Bulletin 07.01.17 insurance requires three year supervised diet history and psych evaluation. NO LAP BAND on patients with BMI over 50.
Keep in mind however, this does not guarantee that because you have a particular Insurance carrier that you are automatically covered for WLS. It is dependent on whether or not your employer elected to include the coverage in your policy. You will still have to check with your Ins carrier to find out about
your coverage.
More info found: Insurance Coverage for Weight Loss Surgery
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