Blue Cross Blue Shield of Michigan covers weight loss surgery. This also applies to the Blue Care Network of Michigan.
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 Michigan.
Blue Cross Blue Shield Of Michigan Pre-Approval Requirements
Weight loss surgery is an effective treatment for morbid obesity. BCBS of Michigan provides full coverage for bariatric procedures provided the patient meets the following requirements:
- The patient’s age is between 18 and 60
- If a patient is less than 18 years of age, a letter should be provided from a physician stating that surgery may prove risky if withheld for a later date. The letter should also state that the physician has evaluated the patient’s mental condition and he/she is fully prepared for the surgery.
- Full coverage for a weight loss surgery procedure will be provided to a patient with a Body Mass Index (BMI) over 40. Class II obese patients are also eligible for coverage provided they suffer from at least one co-morbid condition. Common co-morbid conditions include:
- Coronary artery disease
- Type-2 diabetes
- Obstructive sleep apnea
- Impaired glucose tolerance (diabetes)
- Relevant medical documents need to be submitted as proof that previous weight loss programs tried by the patient did not help. The duration of the weight loss program should have been at least twelve consecutive months. These may include:
- Jenny Craig
- Weight Watchers
- Medically supervised weight loss programs.
- The weight loss surgery should have been prescribed by a physician other than the operating surgeon.
Types of Weight Loss Surgeries Covered By BCBS of Michigan
The weight loss procedures covered by Blue Cross Michigan include:
- Gastric bypass
- Lap Adjustable Gastric Bands
- Gastric Sleeve Procedure
- Vertical Banded Gastroplasty
- Biliopancreatic bypass
- Duodenal switch
You can contact Blue Cross Blue Shield of Michigan to get detailed information regarding the procedures covered.
Procedures Excluded From Coverage
Blue Cross Michigan does not cover procedures considered investigational. They are:
- Open adjustable gastric banding
- Open and laparoscopic sleeve Gastrectomy
- Open and laparoscopic vertical banded Gastroplasty
This list is not comprehensive. Generally, any procedure that is considered experimental will not be covered. If the procedure you’d like to have is not listed on the approved list, it is likely not covered. However, you may want to have your bariatric surgeon’s office contact BCBS of Michigan directly and ask about coverage for a procedure that isn’t listed above.
Is A Second Weight Loss Surgery Covered If Lap Band Doesn’t Work?
Information regarding coverage of a second weight loss surgery is not available. Typically, Blue Cross Blue Shield does offer coverage if your primary procedure does not produce the expected results. Coverage is typically only offered if you followed the post-operative guidelines, changed your lifestyle and sought help from your bariatric surgeon, dietitian and other resources. Please contact BCBS of Michigan directly to find out if they offer coverage for a second procedure.
Revisions to the surgery are covered by Blue Cross Michigan. However, the following documentation must be submitted:
- Date and type of procedure
- Reasons for failure of the procedure
- Patient’s compliance with post-operative diet and exercise regimen
Does Blue Cross Michigan Require A Center Of Excellence?
Blue Cross Michigan has strict guidelines for the requirement of a Center of Excellence.
- The Center of Excellence should be certified by the American College of Surgeons as a level 1 bariatric surgery center.
- The Center of Excellence should also hold a certification by the American Society for Bariatric Surgery as a bariatric surgery Center of Excellence.
- Any bariatric surgeon that accepts Blue Cross Blue Shield of Michigan will know where the surgery has to take place.
Do I Have To Use An In-Network Bariatric Surgeon?
No specific information regarding the requirement of an in-network surgeon is available. However, since Blue Cross Michigan requires a Center of Excellence, using an in-network surgeon is recommended.
Blue Cross Michigan Contact Info to Inquire About Surgery
Blue Cross Michigan can be contacted here or at the customer service number provided on the back of your enrollee ID card.