BCBS Massachusetts – Requirements for Weight Loss Surgery Approval

BCBS Massachusetts Covers Weight Loss Surgery

BCBS Massachusetts covers weight loss surgery. To qualify for coverage, your policy must include coverage. However, not all policies include coverage. To find out if your policy includes coverage, please talk directly to BCBS Massachusetts.

Massachusetts has some of the best state covered benefits for weight loss surgery in the country. If you have BCBS Massachusetts and don’t have coverage consider the state offered health plan.

BCBS Massachusetts – Pre-Approval Requirements

To qualify for coverage of weight loss surgery under the BCBS Massachusetts policy, the following guidelines have to be met:

  • Patients have to be at least 18 years of age at the time of the surgery.
  • The policy of the patient must specifically include weight management or has obesity treatment as an advantage of the process.
  • The patient should have a Body Mass Index of over 40 or over 35 if accompanied by weight-related illnesses like hypertension and diabetes. The policy is also applicable if the patient is 100 pounds above or twice the ideal weight based on his/her age, sex, and height as measured against the Metropolitan Life Insurance Table.
  • The patient has documented evidence of being morbidly obese for five years.
  • Attempts to lose weight led to failure and have been recorded.
  • Obesity should not be caused by any metabolic disorders.

The patient has to meet ALL of the conditions to be approved for bariatric surgery.

In case the contract of the patient clearly states that weight management and/or obesity treatment have been excluded, the procedure will not be approved.

Types of Weight Loss Surgeries Covered by BCBS Massachusetts

The policy provides coverage for the following types of weight loss surgeries for qualified patients:

Patients who undergo any of the procedures covered by their BCBS Massachusetts insurance plan are also required to utilize the following services:

  • Visit a counseling physician every three months after surgery.
  • Up to four visits to a dietitian for nutritional counseling.
  • Drug therapies (covering authorized medicines – as needed).

Procedures Excluded from Coverage

All procedures not included in the list are excluded from coverage even if each case is investigated. If a procedure is medically necessary, coverage will be provided. These procedures include but are not limited to, gastric plication, mini-gastric bypass, and others.

Is A Second Weight Loss Surgery Covered If Lap Band Doesn’t Work?

A second weight loss surgery will only be covered if medically necessary. This typically means that the surgery did not produce the expected results. However, a second procedure is usually not covered if the first procedure wasn’t successful because the patient did not follow post-operative guidelines.


Under the policy, revisions will be deemed ‘medically necessary’ for the following revisions:

  • Addressing complications arising from the bariatric procedure, such as obstructions and non-absorption.
  • Dilation of the gastric pouch causing the bariatric procedure to fail.

Coverage in the second case will be provided if weight loss before dilation has been recorded and the patient’s BMI fulfills the criteria.

Does BCBS Massachusetts Require A Center of Excellence?

No, BCBS Massachusetts does not require a center of excellence. However, you may want to have your surgery performed at a Center Of Excellence.

Do I Have To Use An In-Network Bariatric Surgeon?

Using an in-network bariatric surgeon at any of the facilities in the BCBS Massachusetts Provider Network enables you to get complete coverage along with authorized and in-network benefits. You can also find out-of-state in-network providers.

BCBS Massachusetts’ Contact Info to Inquire About Surgery

Call 855-690-0560 to inquire about your coverage for lap band surgery. Use the toll-free number for contacting BCBS Massachusetts for any other information regarding weight loss surgery.

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