Weight loss surgery is covered by Blue Cross Blue Shield of Texas (BCBSTX). Some rules, however, expressly prohibit weight loss surgery. To discover out if your insurance contains a particular exclusion for weight reduction surgery, contact the contact information at the bottom of this page.
What weight loss surgery is covered by insurance?
Bariatric (weight-loss) surgery is covered by all health funds, but you must have a high level of coverage. Simply contact your health-care provider and provide the following ‘item numbers’: 31569 Gastric Band, 31575 Gastric Sleeve, 31572 Gastric Bypass That’s all there is to it!
Does Blue Cross Blue Shield of Texas cover weight loss programs?
Weight loss surgery is covered by Blue Cross Blue Shield of Texas (BCBSTX). Some rules, however, expressly prohibit weight loss surgery.
Does Blue Cross Blue Shield cover bariatric surgery?
Obese people frequently question whether Blue Cross Blue Shield will support weight loss surgery. The answer is yes, but only if you meet your insurance provider’s specific eligibility requirements. Obesity and its related co-morbidities can be effectively treated with bariatric surgery. You can get Blue Cross Blue Shield bariatric surgery coverage if you can prove that your treatment is medically necessary.
How overweight do you have to be for insurance to cover bariatric surgery?
Your body mass index, a numerical number of your weight in relation to your height, plays a role in determining your eligibility for bariatric surgery. The BMI range of 18-24.9 is seen as ideal. A BMI of 40 or higher is considered morbid obesity.
If you have a BMI of 35-39 with particular serious health concerns like Type 2 diabetes, sleep apnea, or high blood pressure, you may be a candidate for bariatric surgery. A BMI of 40 or more is also a requirement.
Can you get free weight loss surgery?
There are ways to get free weight reduction surgery, but only through weight loss surgery grants or charity care. If you are unable to obtain either, there are numerous methods available to reduce the cost of surgery.
How much weight do you have to lose before gastric sleeve?
The following pre-surgical diet may be required by your surgeon two weeks prior to surgery.
- Certain over-the-counter and prescription drugs should be avoided. Aspirin, ibuprofen (Advil/Motrin), naproxen (Aleve), and acetaminophen (Tylenol/Excedrin) are some of the medications that may be prescribed.
- Reduce body fat: Patients’ safety is improved by reducing fat in the belly and liver.
- Maintain and protect muscle tissue: On a low-calorie diet, increasing protein prevents the body from utilising muscle tissue as an energy source. Instead, the body will burn fat.
- Prepare the body for surgery and recuperation by eating a balanced diet, increasing protein consumption, and taking vitamin and mineral supplements.
- Prepare the patient for the post-surgery diet: The pre-surgery diet (low-calorie, high-protein, low-fat, low-carbohydrate) is very similar to the post-surgery diet (reduced-calorie, high-protein, low-fat, low-carbohydrate) and will help patients adjust to their new eating habits after weight-loss surgery.
Pre-surgery weight loss increases safety
Losing weight prior to surgery reduces the chance of problems and makes weight-loss surgery more secure.
The main goal of decreasing weight before undergoing weight-loss surgery is to reduce body fat in the abdominal area, particularly around the liver. If a patient’s liver is too enormous, a bariatric surgeon may have to postpone surgery. Shortening the operating time for laparoscopic surgery by reducing the size of the liver makes the process safer.
Losing enough weight before surgery allows for a less invasive surgical method (laparoscopic) rather than open surgery for super-obese patients (body mass index more than 50).
Amount of pre-surgery weight loss
Your bariatric surgeon will calculate the amount of weight loss required prior to surgery based on your health, weight, and bariatric procedure. Before undergoing weight-loss surgery, some individuals must reduce 10% of their body weight. Other people find that dropping 15 to 20 pounds before to surgery is sufficient to lessen the chance of problems.
It’s critical to adhere to your surgeon’s pre-surgery dietary and nutritional recommendations. A pre-surgical diet can help your body prepare for surgery and improve the results. It also aids with the adjustment to the dietary and eating adjustments required following weight-loss surgeryand for the rest of your life.
What if your insurance doesn’t cover bariatric surgery?
After you’ve weighed your alternatives and decided that bariatric surgery is the best option for you, you’ll want to know how you’ll pay for it. Many insurance companies acknowledge the importance of obesity and its health repercussions, and will pay for weight loss procedures if you meet plan-specific eligibility requirements.
How to verify your own benefits
Although the staff at your surgeon’s office will verify your benefits as a courtesy, it’s a good idea to call your insurance carrier to confirm coverage and restrictions. You can also read the coverage documentation that your employer and/or insurance company have issued to you.
You’ll want to know if bariatric surgery is covered; if it isn’t, it’ll most likely be included under “obesity” or “weight reduction surgery” in the plan’s exclusions. Bariatric surgery is commonly described as being covered if it is medically required, but this is only partially accurate because it must also be a covered benefit.
You’ll want to know what’s required once you’ve confirmed that your plan covers bariatric surgery. Each plan has its own set of criteria and regulations for determining medical necessity to your insurance carrier’s satisfaction. Although your carrier’s medical policy is the most typical place to obtain benefit criteria, your employer may have an addendum document (“summary plan document/description”) that explains extra or other requirements for particular treatments. Because the requirements of the medical policy are often superseded by a summary plan document, it’s crucial to know if an addition like this applies.
Medical necessity vs. coverage exclusions
Despite the fact that you may meet basic and widely accepted medical necessity requirements, your insurance company is not compelled to cover bariatric surgery. Your insurance will not consider you for coverage if weight loss surgical services are designated as an exclusion, regardless of your BMI or concomitant conditions. The denial rationale does not imply that surgery is not medically required, but rather that they do not give this form of coverage, for which there is no appeals process.
Cash paying for surgery
There are alternative solutions open to you if your insurance does not cover bariatric surgery. Consultations, nutritional counseling, pre- and post-operative tests, labs, and follow-up visits may be covered depending on the plan language, but surgery is not. Verifying your benefits will assist us in estimating potential costs for you during your appointment.
How to meet insurance criteria
You’ll meet with a surgeon for a consultation once your benefits have been validated. Your height, weight, and BMI will be recorded, as well as any concomitant conditions and previous unsuccessful attempts at non-surgical weight loss. If your plan calls for a medically supervised weight loss program, you’ll meet with a nutritionist on a monthly basis for the duration of your treatment.
Because a psychological clearance is the most prevalent insurance criterion, you should make an appointment with a mental health specialist who will assess your candidacy for bariatric surgery. It’s crucial to rule out psychological issues, any type of disordered eating, a lack of competence to provide informed consent, and a failure to follow pre- and post-surgical instructions.
Insurance authorization process
The authorisation process can commence if all pre-surgical and insurance requirements have been satisfied. Your pertinent medical records will be compiled and sent to the clinical review department of your insurance company. A determination can take up to four weeks, but it is more common to receive one in two weeks. You’ll be advised of the approval or denial once we hear from your insurer. Surgery can be planned or confirmed once you’ve gotten approval.
If your operation is denied, we will examine the decision and follow the measures provided by your insurance company. Denials can occur for a variety of reasons, including a lack of paperwork or a lack of agreement on criteria that are ambiguous or open to interpretation.
Appeals
Because appeals deadlines may be approaching quickly, it’s critical to properly evaluate denials.
As a first step in this procedure, a peer-to-peer option is usually provided. A peer-to-peer meeting is a prearranged meeting between your surgeon and the medical director of the insurance company to address the denial. When this conference is feasible, it’s quite beneficial since we can get precise input from a reviewing authority about what additional the insurance company expects us to provide or what they want you to accomplish in order to qualify. At the time of this debate, the rejection may be affirmed or reversed, but it’s usually just a tool for moving forward with the appeal.
If an appeal is necessary, we will obtain any additional documentation that was previously overlooked. If more tests or office visits are needed, they should be planned as quickly as possible to ensure that they are completed before the appeal time expires.
There could be several stages to the appeals process. A second- or third-level appeal can be requested if necessary, with the final step typically including submission to an outside party for review. Because external review organizations are not linked with our office or your insurance provider, they can conduct an unbiased assessment of your clinical documentation.
What can I do to ensure approval?
A patient health history questionnaire will be given to you prior to your session. Because it will be translated into your medical record, which will be evaluated by the insurance provider, it is critical that you fill this out entirely and truthfully.
Bring a copy of any paperwork (medical chart notes, personal records, logs, or receipts) from past weight loss attempts, whether by diet, exercise, or medical supervision, to be reviewed and scanned into your chart.
If you’ve had a previous weight reduction treatment, you should get copies of your operative report, as well as pre- and post-surgical visits, to demonstrate your commitment to follow-up and adherence to any suggestions provided by your previous practitioner.
The single most important thing a patient can do to increase the chances of their insurance company approving their claim is to follow the medical policy’s rules to the letter (or Summary Plan Document, if applicable). Medically supervised diets are generally need to be followed for several months and should be spread out by about 30 days. Failure to keep scheduled appointments for several months in a row will almost always result in denial, delaying surgery or forcing you to restart the prescribed regimen from the beginning.
Does HMO insurance cover weight loss surgery?
Even if you have health insurance, whether it’s a PPO or an HMO, it’s unlikely that it will cover all of the costs connected with weight reduction surgery. Program fees, deductibles, and co-insurance are examples of typical out-of-pocket payments. After we have verified your insurance benefits, we will study your coverage and tell you of your out-of-pocket expenditures. We make every effort to have this information available at the time of your consultation.
Does Fepblue cover weight loss surgery?
Benefits for bariatric and transplant care are only available at Blue Distinction Centers (see pages 62 and 66). If you’re considering covered cardiac treatments, cancer treatment, knee or hip replacement, or spine surgery, a Blue Distinction Center might be a good option.
How long does it take for insurance to approve gastric sleeve?
A growing number of states have approved legislation requiring insurance companies to provide weight-loss surgery for people who fulfill the NIH surgical requirements. While weight-loss surgery is commonly covered by insurance, the approval process can be lengthy and confusing. Working with your surgeon and other professionals gives you the best chance of getting insurance coverage approved.
Steps to obtain insurance coverage for bariatric surgery:
- Most insurance companies are aware of the health risks associated with obesity and will cover the costs of surgical weight loss in qualified patients. Every insurance plan, however, is unique.
- We begin the process of obtaining insurance authorization once you have completed our preparatory program, satisfied all of your insurance company’s requirements, and the surgeon has cleared you for surgery. We start by submitting your medical records to your insurance company, requesting that they fund the procedure. The insurance company may take two to four weeks to react with a decision.
- Once we obtain permission or refusal from the insurance carrier, we will contact you. If the coverage is accepted, the patient is given a surgery date and a pre-op appointment. If coverage is refused, we investigate the cause for the decision and file an appeal with the insurance carrier.