Blue Cross Blue Shield CareFirst Maryland 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 CareFirst Maryland.
BCBS CareFirst Maryland Pre-Approval Requirements
Morbid obesity can be cured through weight loss surgery. Blue Cross Blue Shield CareFirst Maryland has outlined the following requirements for approving a patient for a bariatric procedure with full coverage.
- The patient should be over 18 years of age at the time of applying for the weight loss surgery
- The patient should have been suffering from morbid obesity for a period of at least two years preceding the surgery
- The patient should either have a BMI of over 40 or have a BMI in the 35 – 40 range with a co-morbid condition. Co-morbid conditions considered for approving the surgery include:
- Cardiovascular Disease
- Sleep Apnea
- Joint Disease
- The patient needs to undergo a psychological evaluation to determine if he/she is prepared for the surgery and whether or not he/she understands the procedure completely.
- The patient has to submit documentation that he/she completed a diet plan/program for at least six months, or two plans of at least three months each, in the one-year period before the surgery without success. The diet plan should not involve any surgical measures.
Types of Weight Loss Surgeries Covered by Blue Cross Blue Shield CareFirst Maryland
Coverage for weight loss surgeries from Blue Cross Blue Shield CareFirst Maryland is restricted to procedures that have proven to be effective. These are considered medically necessary and include:
- Gastric Stapling
- Gastric Bypass
- Sleeve Gastrectomy
- Adjustable Gastric Banding
- Biliopancreatic Bypass with Duodenal Switch
Any patient who meets the criteria for morbid obesity as outlined in the pre-approval requirements will receive complete coverage for the procedure from Blue Cross Blue Shield CareFirst Maryland.
Procedures Excluded from Coverage
Procedures that are considered experimental and investigational are excluded from coverage. These include but are not limited to:
- Jejunoileal Bypass
- Transoral Gastroplasty
- Gastric Wrapping
- Biliopancreatic Bypass Without Duodenal Switch
- Gastric Balloon
These procedures don’t meet the necessary criteria to be considered medically necessary.
Is a Second Weight Loss Surgery Covered If Lap Band Doesn’t Work?
Though we were unable to find any information on this, BCBS plans generally allow re-operations.
Revisions are usually covered for complications after surgery or inadequate weight loss in most BCBS centers.
Does BCBS CareFirst Maryland Require a Center of Excellence?
No, Blue Cross Blue Shield CareFirst Maryland does not require a Center of Excellence. However, most BCBS plans do. You may be required to have the surgery at a Blue Distinction Center.
Do I Have To Use An In-Network Bariatric Surgeon?
No, you don’t have to use an in-network bariatric surgeon though the costs will be lower if you do. It may be recommended that you have surgery at a Blue Distinction Center.
Contact BCBS CareFirst Maryland
You can call BCBS CareFirst at (866) 520-6099 or visit their website.