Blue Cross and Blue Shield Service Benefit Plan Surgical Procedures FBF22.05b.1 Page 3 of 5 1/1/2020 Benefits for the surgical treatment of morbid obesity, performed on an inpatient or outpatient basis, are subject to the pre-surgical requirements listed below. Internal Medical Policy Committee 1-20-2022 Revision with coding updates; Internal Medical Policy Committee 11-29-2022 Coding update - These may include: The weight loss surgery should have been prescribed by a physician other than the operating surgeon. . endobj If the individual does not meetALLof the selection criteria for bariatric surgery, the procedure will be denied as not medically necessary. *GP( @ r UQ T9 To contact Blue Cross Blue Shield of Alabama, you can either log into their official websitehttps://www.bcbsal.org/web/index.html, use the telephone numbers on the back of your BCBSA ID card or call 1-888-267-2955 for family and individual services. The individual's medical record documentation should indicate that all psychosocial issues have been identified and addressed; The individual must be able to show decisional capacity and maturity in the psychological evaluation and provide informed assent for surgical management; The individual must be capable and willing to adhere to nutritional guidelines postoperatively; The individual must have a supportive and committed family environment; Selection criteria is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. However, there is a lack of evidence on the optimal timing, intensity and duration of nonsurgical attempts at weight loss, and whether a medical weight loss program immediately preceding surgery improves outcomes; The individual must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery. *GP( @ r UQ T9 The member must meet all requirements. For high BMI individuals in whom the duodenal switch may be difficult, it is reasonable to do a sleeve gastrectomy as the first stage of an intended two-stage duodenal switch. *GP( @ r UQ T9 These include but are not limited to: Repeat surgical procedures for revision or conversion to another surgical procedure may be considered medically necessary when the initial bariatric surgery was medically necessary (and the individual continues to meet all the medical necessity criteria for bariatric surgery); Reimbursement will be 75% of the fee schedule . *GP( @ r UQ T9 Before calling make sure you see our questions to ask before calling your insurance company. endobj endstream *GP( @ r UQ T9 Blue Cross Blue Shield Of Michigan Pre-Approval Requirements. *GP( @ r UQ T9 O Surgical repair to correct perioperative or late chronic complications of a bariatric procedure may be considered medically necessary when there is documentation of a surgical complication related to the perioperative or late chronic complications of a bariatric procedure. This policy provides direction on Blue Cross Blue Shield of North Dakota (BCBSND) reimbursement for global surgical package and subsequent services provided within the global surgery days. or 100 percent over ideal weight or a body mass index (BMI) of at least 40 or a BMI of 35 with comorbidities. A weight which is at least 100 lbs. endobj 0BQp>>=5>g-9{{w[(e#(Px8. Any bariatric surgeon that accepts Blue Cross Blue Shield of Michigan will know where the surgery has to take place. 0 Request Out of Network Benefits. hbbd```b`` "HE`Z09D|&&_IO`" H2nb3w Z'[A$)X}L?o F_ Morbid obesity is further defined as a condition of consistent and uncontrollable weight gain that is characterized by a weight which is at least 100 lbs. *GP( @ r UQ T9 However, your deductible and out of pocket costs may be significantly lower if you do. *GP( @ r UQ T9 Benotti PN, Still CD, Wood GC et al. As a result, some centers require active participation in a formal weight reduction program that includes frequent documentation of weight, dietary regimen, and exercise. Fellow, American Society for Metabolic and Bariatric Surgery; SJ Magazine "Top Docs" - 2014, 2015, 2016, 2019, 2020, 2021, 2022; South Jersey Magazine "Best Doctors . *GP( @ r UQ T9 *GP( @ r UQ T9 Primary Care Physician's Letter. 13 0 obj *GP( @ r UQ T9 Bariatric Surgery in Adolescents and Children Return to Clinical Indications. Covered Diagnosis Codes for Procedure Codes: 43644, 43770, 43775, 43843, 43846, and S2083, Covered Diagnosis Codes for Procedure Code: 43845, Internal Medical Policy Committee 3-16-2020 Revision, Internal Medical Policy Committee 11-19-2020 Revision, Internal Medical Policy Committee 11-23-2021 Revision. The individual's understanding of the procedure and ability to participate and comply with life-long follow-up and the life-style changes (e.g., changes in dietary habits, and beginning an exercise program) are necessary to the success of the procedure. Provider Resource Center - BCBSWNY Blue Cross Blue Shield Association. This does permit subsequent assessment of both the efficacy of the sleeve (to see whether the second stage is really needed), assessment of the compliance of the individual (to see whether the more complicated procedure is justified) or to examine the metabolic and nutritional effects of the sleeve (to see whether potential further metabolic derangements of the duodenal switch would make it unadvisable). Sleeve gastrectomy is an eligible procedure as a first stage of a two-stage procedure or as a sole definitive procedure; Laparoscopic adjustable gastric banding using an FDA approved adjustable gastric band: Laparoscopic adjustable banding is an eligible procedure ONLY when a contraindication to biliopancreatic bypass with duodenal switch, Rou-en-Y gastric bypass, and sleeve gastrectomy is documented in the medical record. endobj 773 0 obj <>/Filter/FlateDecode/ID[<675B09CE55CCC14F9AD95E27B755F731>]/Index[748 42]/Info 747 0 R/Length 117/Prev 507134/Root 749 0 R/Size 790/Type/XRef/W[1 3 1]>>stream To find out which services are covered under your policy at any facility, please call the customer service number listed on your Blue Cross and Blue Shield of Illinois member ID card. Weight loss surgery is an effective treatment for morbid obesity. Endoscopic procedures including but not limited to; StomaphyX device or restorative obesity surgery (ROSE) procedure; Gastrointestinal Liners (e.g., the EndoBarrier); Biliopancreatic bypass (the Scopinaro procedure) or laparoscopic; Vagal nerve blocking (VBLOC) therapy (neuromodulation non-metabolic), also known as the Maestro implant or Maestro rechargeable system; Single anastomosis duodenal-ileal bypass with Sleeve Gastrectomy (SIPS or SADI), Changed Title from Obesity to Bariatric Surgery, Sleeve gastrectomy is an eligible procedure as a first stage of a two-stage procedure. The site may also contain non-Medicare related information. 3 0 obj *GP( @ r UQ T9 5 0 obj *GP( @ r UQ T9 CG-SURG-83 Bariatric Surgery and Other Treatments for - Anthem Representatives are available 24 hours a day, seven days a week. Bariatric surgery should be performed in appropriately selected individuals by surgeons who are adequately trained and experienced in the specific techniques used and in institutions that support a comprehensive bariatric surgery program, including long-term monitoring and follow-up post-surgery. Bariatric Surgery for Morbid Obesity. *GP( @ r UQ T9 . *GP( @ r UQ T9 1J-z](5K+XkXU)zc+2gUnRsXuQ@t>icv- {7V}*ymha.JS10NL](wnj`"5c+8L5TwB0mgbP{C]Z#H4:s PCD4N0"Pz}KP7A@mDY*/yiI @Z22*;/-"i1-mhqe,@e*De)KW8vYiI @Z22*;/-"iq@M&, e * PY$(NY`!%'NZ2 AHTyiHV}%0D0r, e9(KDElW4m'NZ2 AHTyiHm>e ,@e(, 8e"Q4Z'NZ2 AHTyiHu}fOY? e,@e*bs HYA$RV A*6 bhu/D0Cxi9 H! The individual's medical record documentation should indicate that all psychosocial issues have been identified and addressed; Psychological evaluation documentation must be within the last year; Individual selection is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. Understanding Health Care Costs and Quality, Provider Finder -Network Selection Criteria, HMO Provider Network Important Information, Making Your Health Insurance Work For You, Prescription Drug Changes and Pharmacy Information, Machine Readable Files for Transparency in Coverage. The answers to these questions will vary considerably based . bluecross blueshield fed blue bariatric Guide bluecross blueshield fed blue bariatric Requirements bluecross blueshield fed blue bariatric web address bluecross blueshield fed blue bariatric valid Username & Password. Repeat surgical procedures for revision or conversion to another surgical procedure may be considered medically necessary when the initial bariatric surgery was medically necessary (and the individual continues to meet all the medical necessity criteria for bariatric surgery);andwhenANYONEof the following criteria is met: Internal Medical Policy Committee 11-29-2022 Coding update - December 06, 2022, Fargo (Headquarters) According to Blue Cross/Blue Shield of California Medically Necessary. 0 Full coverage for a weight loss surgery procedure will be provided to a patient with a Body Mass Index (BMI) over 40. 2023 Blue Cross Blue Shield of North Dakota, Please wait while your form is being submitted, Directory Validation Instructions (No Surprises Act), Recredentialing & Credentialing Applications. endstream accredited by the metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, . endobj Anthem BCBS may cover weight loss surgery as long as your policy does not specifically exclude coverage. Contact 866-773-2884 for authorization regarding treatment. <>>> So we are happy to report that manyAnthem BCBS policies cover weight loss surgery. <> outpatient follow-up. PDF FEP Blue Focus Prior Approval List - Premera Blue Cross Global Surgical Package | BCBSND Yes, some Blue Cross Blue Shield plans may not cover bariatric surgery. Requests for bariatric surgery for patients less than 18 years of age should include documentation that the primary care physician has addressed the risk of surgery on future growth, the patient's maturity level and the patient's ability to understand the procedure and *GP( @ r UQ T9 In addition, some sites may require you to agree to their terms of use and privacy policy. To find out which services are covered under your policy at any facility, please call the customer service phone number on the back of your Blue Cross and Blue Shield of Texas member ID card. Blue Distinction Centers for Bariatric Surgery, along with the Blue Distinction Centers for Cardiac Care, Blue Distinction Centers for Knee and Hip Replacement, Blue Distinction Centers for Maternity Care, Blue Distinction Centers for Spine Surgery, Blue Distinction Centers for Substance Use Treatment and Recovery and Blue Distinction Centers for Transplants are a key part of our efforts to work with doctors and facilities to improve the overall quality, and resulting affordability of specialty care. *GP( @ r UQ T9 To view this file, you may need to install a PDF reader program. Note: Designation as Blue Distinction Centers means these facilities' overall experience and aggregate data met objective criteria established in collaboration with expert clinicians' and leading professional organizations' recommendations. Learn more about weight loss surgery at Rocky Mountain Associated Physicians www.RMAP.com (801) 268-3800. Morbid obesity is defined as a condition of consistent and uncontrollable weight gain that is characterized by. endobj It is important to know that your employer can typically opt-out of weight loss surgery insurance coverage for their employees policies. Morbid obesity is further defined as a condition of . *GP( @ r UQ T9 *GP( @ r UQ T9 stream website at www.calpers.ca.gov. endobj Covered gastric restrictive or malabsorpive procedures must be performed in an approved facility with one of the following accreditations, https://www.facs.org/search/bariatric-surgery-centers. The policy bulletins on this web site were developed to assist Highmark Blue Cross Blue Shield in administering standard plan benefits and do not constitute a description of plan benefits. Sitemap, Bariatric Surgery 101 Guide: Read This First. endobj Does Blue Cross Blue Shield of Alabama (BCBS) cover bariatric surgery? *GP( @ r UQ T9 <> Any bariatric surgeon that accepts Blue Cross Blue Shield of Michigan will know where the surgery has to take place. States Where Insurance Is Required To Cover Bariatric Surgery Under the Affordable Care Acts Essential Health Benefits Benchmark Plans, 23 states require that all individual, family, and small group insurance plans cover . *GP( @ r UQ T9 . *GP( @ r UQ T9 PDF BCBSM Medicare Advantage PPO Weight Loss Surgery Enhanced Benefit Log In to the Shopping Cart, Need to Make a Payment? *GP( @ r UQ T9 PDF 2023 Benefit Summary Book 6 0 obj Bariatric Surgery . Most PDF readers are a free download. *GP( @ r UQ T9 The following are three types of weight loss procedures that are covered by BCBS Alabama. <> PDF Bariatric Surgery Selection Criteria - Blue Cross Blue Shield Association Weight loss surgery is an effective treatment for morbid obesity. This Program aligns with the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Below, you'll learn what factors into the cost of . The best option is to call them directly and ask if your policy includes coverage for CPT Code 43775. stream This website uses cookies to improve your experience. Medical policies for providers | Wellmark ,_*:1Ch_WpK3R6UYo gD_){6^9V0ljRoZY=;~lov'xmv'}y3-{lZjUTi:hnS: ]}}_v$j&m.~.?NIcWX*}pO=-f)/QeQ7vuT'UJ_\}Sj}NU~WOT}J"^ We'll assume you're ok with this, but you can opt-out if you wish. *GP( @ r UQ T9 The following bariatric procedures are considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature. patient education. Please note that not all policies include coverage. Revised: July 2022. Bariatric Journal is a leading publication for bariatric surgery guides and information. Effective January 01, 2023, Internal Medical Policy Committee 3-23-2023 Revision - ; Bariatric surgery may be indicated for patients 18 to 60 years of age. 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