Anthem Blue Cross Blue Shield (BCBS) Nevada – Bariatric Surgery Insurance Coverage
Blue Cross Blue Shield is the largest health insurance company in the United States and provides a wide range of plans including Medicare, group, individual and family. Blue Cross Blue Shield also offers a number of HMO and PPO options. Each of these plans can vary drastically, despite being underwritten by the same insurance company. For example, HMO plans will require a primary care physician referral for any specialist visits, while PPO customers can choose their own doctor. Bariatric surgery coverage can vary between plans as well. Some plans cover weight loss surgery while others don’t. Even plans that cover bariatric surgery may have different co-pays, and out-of-pocket expenses.
Does my Anthem BCBS policy cover weight-loss surgery?
This is the first and most important question to ask of your insurance company, HR manager or insurance agent before considering surgery. You can look up the details of your insurance plan by finding the coverages and exclusions section of your insurance documents that may have been emailed or mailed to you. These sections should offer detailed information on what is and isn’t covered, including specific procedures as well as any out-of-pocket expenses you may incur.
What will my out-of-pocket expenses be?
Your out-of-pocket expenses will depend on your benefits which can be found in the coverages and exclusions section of your insurance documents. You should also speak directly to your insurance company to understand what charges you may be responsible for. Typically, Anthem BCBS customers will be subject to a co-pay, deductible and maximum out-of-pocket expense. Be mindful that all of these reset on January 1. So, if you are approaching the end of the year and you have utilized your insurance benefits significantly, you may be better off starting the process now versus at the beginning of the following year.
Does Anthem BCBS Nevada have prerequisites for coverage?
The short answer is yes. BCBS Nevada and all other insurance companies want to ensure that surgery is absolutely necessary before approving coverage. Therefore, they require documentation to that effect. Each plan may have different requirements, but in general, the following are guidelines stipulated by most insurance companies
Body mass index or BMI: a BMI of 35 or over with one or more comorbidities or obesity related diseases; or a BMI of 40 or over regardless of comorbidity is necessary to qualify for bariatric surgery. These are guidelines set forth by the FDA. Comorbidities can include type two diabetes, high blood pressure, high cholesterol, sleep apnea and more
Morbid obesity: A diagnosis of morbid obesity must have been established for a certain amount of time prior to surgery. This can be up to three years. Your primary care physician will have to submit documentation to that effect. If no documentation has been established, timestamp photographs may be acceptable.
Medical weight loss: Also known as physician supervised weight loss, participation in a medical weight loss program is a likely prerequisite for surgery. This weight loss program may be required in the three or even six months leading up to surgery. During this time, patients will have to prove their participation and the treating physician will submit periodic evaluation to the insurance company.
Non-Surgical Weight Loss History: the patient may have to submit documentation of failed nonsurgical diet and exercise programs in the period before surgery. These can include commercial diets such as Jennie Craig and Weight Watchers.
Smoking: Patients must quit smoking at least two months before surgery.
What procedures are covered by Anthem BCBS Nevada?
Major, proven bariatric surgical procedures such as the gastric sleeve and the gastric bypass are typically covered if the policy covers bariatric surgery in general. The duodenal switch, while less popular, may also be covered by the policy. The Lap-Band, or adjustable gastric band, may also be covered, but we typically do not recommend this to our patients as we have seen an unacceptably high long-term complication rate.
The gastric balloon is not covered by BCBS Nevada; and any other procedure considered experimental or unproven is typically not covered by insurance.
Revisions to a previous bariatric procedure may be covered on a case by case basis. Most commonly, the removal of a Lap-Band and revision to a gastric sleeve is a covered procedure. It is important that you speak to us as well as your insurance company to understand the qualifying criteria for revisions
What if pre-authorization is denied or your policy does not cover bariatric surgery?
As mentioned above, not all policies will cover bariatric surgery and in this case, there’s not much that can be done other than to consider a cash or self-pay gastric sleeve. VIPSurg offers an excellent cash pay rate of $10,995 for patients interested in the gastric sleeve. You can get more details about our gastric sleeve cash pay rate here.
There are times where Anthem BCBS Nevada may deny preapproval for a bariatric procedure. Many times, this is because of a clerical error in the application. Therefore, the first step is to get a reason for the denial in writing. Once you have that, we encourage you to speak to us about any corrections to your application or to complete any prerequisites and stipulations that may have been missed.
More information from your insurance plan
Anthem Blue Cross Blue Shield of Nevada can be contacted by phone, Live Chat or online through your insurance portal here: