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BCBS Kansas City Criteria for Weight Loss Surgery Coverage

OC Staff Am I Covered

BCBS Kansas (BCBSKC) does cover weight loss surgery when the appropriate criteria are met. However, BCBSKC does point out in its policy introduction that:

“Most local contracts have a specific exclusion for morbid obesity surgery…regardless of medical necessity.”

While every insurance company has local policies with a specific exclusion of weight loss surgery, I haven’t seen many that list this in the main policy. I would suggest calling your local HR or BCBSKC by using the contact information at the bottom of this page.

BCBSKC Criteria for Coverage

BCBS Kansas (BCBSKC) will provide coverage for weight loss surgery when it is deemed to be medically necessary because the criteria below are met.

BCBSKC has an interesting policy for weight loss surgery. It is relatively vague compared to most other BCBS weight loss surgery policies.
Instead of specific criteria a lot is left up to the surgeon.

For adults:

“Bariatric surgery is considered medically necessary for the treatment of morbid obesity that has not responded to conservative measures.”

“Further, bariatric surgery should be performed in appropriately selected patients, by surgeons who are adequately trained and experienced in the specific techniques used, and in institutions that support a comprehensive bariatric surgery program, including long-term monitoring and follow-up post-surgery.”

Under 18 years old:

  1. Very severe obesity, Body Mass Index of 40 or more with co-morbidities that are poorly controlled.
  2. Or, a Body Mass Index of 50 or greater with less severe comorbidities.

Types of weight loss surgeries covered by BCBS Kansas City

For Adults:

  1. Open and laparoscopic gastric bypass
  2. Adjustable gastric bands (i.e. Lap Band or Realize Band)
  3. Sleeve gastrectomy
  4. Open or laparoscopic biliopancreatic bypass with duodenal switch may be considered for patients with a BMI over 50.

Are lap band fills covered?

Yes, lap band fills are covered by your insurance if you had the procedure done using your insurance coverage.

Which procedures excluded from coverage?

Anything that is considered investigational, including:

  1. Endoscopic procedures as a primary or a revision procedure.
  2. Mini-gastric bypass
  3. Biliopancreatic bypass without duodenal switch
  4. Gastric wrapping

Bariatric surgery is also not covered as a cure for type 2 diabetes.

Is a second weight loss surgery covered if a Lap Band doesn’t work?

If the initial surgery worked and the patient lost weight but then regained weight due to dilation of the gastric pouch, then a second surgery will be covered if:

  • The patient has been compliant with exercise and nutrition program since the surgery and still meets the criteria for surgery.

Are revision surgeries covered?

Yes – but only if the first procedure worked and then, because the gastric pouch stretched, the patient regained weight. The patient has to be compliant with the recommended diet and exercise program.

Does BCBSKC Require Center of Excellence?

Blue Cross Blue Shield generally requires surgery be performed at a BCBS approved bariatric center.

Do I have to use an In-Network Bariatric Surgeon?

Your out-of-pocket expenses are higher if you do not use an in-network surgeon but you still must have surgery at a BCBS approved facility.

BCBSKC Contact Information

Contact Blue Cross Blue Shield of Kansas City here.

BCBSKC Weight Loss Surgery Full Coverage Statement

BCBSKC’s full insurance coverage statement is here.


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