BCBS of Michigan Weight Loss Surgery – How to Avoid a Denial
Your Blue Cross Blue Shield Michigan 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
- Coverage Requirements
- Coverage Plans
- Covered Procedures
- Appealing a Denial
- Find a Weight Loss Surgeon
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 policy covers bariatric surgery, click here to contact a surgeon and ask for a free insurance check.
Find a Weight Loss Surgeon
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 Blue Cross Blue Shield Michigan for bariatric surgery in the United States, you must meet the following criteria:
- Bariatric surgery may be indicated for patients 18 to 60 years of age. Patients older than 60 may be considered if it is documented in the medical record that the patient's physiologic age and co-morbid condition(s) result in a positive risk-benefit ratio
- Diagnosis of Morbid obesity, defined as
- a Body Mass Index (BMI) greater than 40
Or
- BMI 35 – 39.9 AND one of the following
- Degenerative joint disease (including degenerative disc disease)
- Hypertension
- Hyperlipidemia, coronary artery disease
- Presence of other atherosclerotic diseases
- Type 2 diabetes mellitus
- Sleep apnea
- Congestive heart failure
Use this BMI Calculator to check your body mass index…
- The patient has been clinically evaluated by an M.D. or D.O. (or their authorized delegate (e.g., physician assistant, etc.). The physician has documented failure of non-surgical management including a structured, professionally supervised (physician or non-physician) weight loss program for a minimum of one of the following:
- Six full, consecutive months (180 days) within the last four years prior to the recommendation for bariatric surgery (for BCBSM patients)
- Six full, consecutive months (180 days) within the last two years prior to the recommendation for bariatric surgery (for BCN patients)
- NOTE: The six full consecutive month (180 days) weight loss program listed above is waived for super morbidly obese individuals who have a BMI > 50. Documentation should include periodic weights, dietary therapy and physical exercise, as well as behavioral therapy, counseling and pharmacotherapy, as indicated
- Documentation that the primary care physician and the patient have a good understanding of the risks involved and reasonable expectations that the patient will be compliant with all post-surgical requirements
- A psychological evaluation must be performed as a pre-surgical assessment by a contracted mental health professional in order to establish the patient's emotional stability, ability to comprehend the risk of surgery and to give informed consent and ability to cope with expected post-surgical lifestyle changes and limitations. Such psychological consultations may include one unit total of psychological testing for purposes of personality assessment (e.g., the MMPI-2 or adolescent version, the MMPI-A)
Adolescents Requirements
Requests for bariatric surgery for patients younger 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 comply with postoperative instructions, as well as the adequacy of family support.
Revision Requirements
In cases where a revision of the original procedure is planned because of failure due to anatomic or technical reasons (e.g., obstruction, staple dehiscence, etc.) or excessive weight loss of 20% or more below ideal body weight, the revision is determined to be medically appropriate without consideration of the initial preoperative criteria. The medical records should include documentation of:
- The date and type of the previous procedure
- The factor(s) that precipitated the failure or the nature of the complications from the previous procedure that necessitate the takedown
- NOTE: If the indication for the revision is a weight gain or a failure of the patient to lose a desired amount of weight due to patient non-adherence, then the patient must re-qualify for the subsequent procedure and meet all the initial preoperative criteria.
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.
Blue Cross Blue Shield Michigan Contact Information and Full Medical Policy on Bariatric Surgery
- By Phone: 1-313-225-9000
- Contact Blue Cross Blue Shield Michigan
- Full Bariatric Surgery Medical Policy for Blue Cross Blue Shield Michigan
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.
Blue Cross Blue Shield Michigan does cover weight loss surgery, but your specific policy must include it in order for you get it covered.
Following are a list of Blue Cross Blue Shield Michigan 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)
- 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:
- 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.
03.
Covered Weight Loss Procedures
SECTION SUMMARY:
- Gastric Sleeve
- Gastric Bypass
- Lap-Band
- Duodenal Switch
Please see below for the procedures Blue Cross Blue Shield Michigan covers, might cover under certain circumstances, and those that are not covered under any circumstances:
Procedures That ARE Covered
- Gastric Sleeve Surgery
- Roux-en-Y Gastric Bypass
- Lap-Band
- Duodenal Switch
Procedures That MIGHT BE Covered
The following procedures MIGHT BE covered by Blue Cross Blue Shield Michigan:
- Revision Surgery (either Lap-Band Revision or Gastric Bypass Revision)
Procedures That Are NOT Covered
The following procedures are NOT covered by Blue Cross Blue Shield Michigan:
- Gastric Balloon
- AspireAssist
- Vertical Banded Gastroplasty
- Mini Gastric Bypass Surgery
- Stomach stapling
- Endoscopic procedures (e.g., insertion of the StomaphyX™ device) as a primary bariatric procedure or as a revision procedure, (e.g.,, to treat weight gain after bariatric surgery to remedy large gastric stoma or large gastric pouches)
- Any bariatric surgery for patients with Type 2 diabetes who have a BMI of less than 35
- Biliopancreatic bypass without duodenal switch
- Long-limb gastric bypass procedure (e.g., >150 cm)
SECTION SUMMARY:
- General Appeal Instructions
- Appeal Details Specific to Blue Cross Blue Shield Michigan
If Blue Cross Blue Shield Michigan 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 Blue Cross Blue Shield Michigan 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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