Blue Cross Blue Shield North Carolina covers weight loss surgery. To qualify for coverage of weight loss surgery, your policy must include coverage. Please note that not all policies include coverage. So, to find out if your policy includes coverage, please talk directly to Blue Cross Blue Shield North Carolina.
Blue Cross Blue Shield North Carolina Pre-Approval Requirements
BCBSNC provides coverage for weight loss surgery when it is deemed medically necessary. The pre-approval requirements are listed below.
- The patient should be at least 18 years old at the time of the surgery. Though weight loss surgery may be recommended for adolescents, the patient should understand the procedure and give informed consent.
- The patient has a Body Mass Index (BMI) of over 40. Patients with a BMI of over 35 are considered for weight loss surgery coverage provided that they suffer from a co-morbid condition, such as diabetes mellitus, hypertension and sleep apnea.
- The patient should be thoroughly analyzed to determine whether he/she is fit for the surgery and later must follow the post-operative diet and lifestyle guidelines.
- If there is no specific, treatable medical cause for the morbid obesity, the patient may undergo surgery.
The patient has to fulfill all the requirements outlined above in order to be approved for weight loss surgery.
Types of Weight Loss Surgeries Covered By Blue Cross Blue Shield North Carolina
The following weight loss surgeries are covered by BCBSNC:
- Sleeve Gastrectomy
- Short Limb Roux en Y Gastric Bypass
- Long Limb Roux en Y Gastric Bypass
- Adjustable Gastric Banding
- Can only be used in morbidly obese adult patients according to FDA guidelines
- Biliopancreatic Bypass without Duodenal Switch
- Considered only for patients with a BMI of over 50
Procedures Excluded From Coverage
The following weight loss procedures are considered investigational and are not covered by BCBSNC:
- Vertical-Banded Gastroplasty
- Jejunoileal Bypass
- Garren-Edwards Gastric Bubble
- Gastric Wrapping
- Gastric Bypass Using A Billroth II Type Of Anastamosis
- Biliopancreatic Bypass (except as detailed above)
- Endoscopic Procedures
- Two-Stage Bariatric Surgery Procedures
- Gastric Electrical Stimulation
Coverage will not be provided in the following situations:
- Adjustable Gastric Banding for patients under 18 years of age
- Patient has a BMI <35
- As a cure for Diabetes Mellitus
Is A Second Weight Loss Surgery Covered If Lap Band Doesn’t Work?
No information is available online regarding this. However, Blue Cross Blue Shield plans generally cover a second weight loss surgery if lap band doesn’t work. Its recommended that you call BCBS of North Carolina directly and ask a representative.
Revisions are covered if:
- Medical complications arise due to the original procedure
- The procedure failed because of dilation of the gastric pouch
- The procedure will be revised to treat the issue.
Does Blue Cross Blue Shield North Carolina Require A Center Of Excellence?
No information is available regarding the surgery being performed at a Center of Excellence. Blue Cross Blue Shield plans vary from state to state. So, please enquire directly from Blue Cross Blue Shield North Carolina. Its likely that they may require you to have your surgery at a Blue Distinction Center.
Do I Have To Use An In-Network Bariatric Surgeon?
Using an in-network is not required, but it helps keep costs down.
Blue Cross Blue Shield North Carolina Contact Info to Inquire About Surgery
Call the number given on the back of your ID Card. If you are not a member, call 1-800-446-8053 or contact BCBS of North Carolina online.