Horizon Blue Cross Blue Shield New Jersey 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.
Horizon Blue Cross Blue Shield New Jersey Pre-Approval Requirements
Weight loss surgery for treating morbid obesity is considered medically necessary if the patient fulfills the following criteria:
- The patient should be at least 18 years of age AND/OR the patient’s skeletal growth is complete.
- Weight loss surgery for patients under 17 years of age is not considered medically necessary unless full skeletal growth has been reached and the patient suffers from a co-morbid condition, such as sleep apnea or hypertension.
- The patient is morbidly obese (i.e. has a Body Mass Index (BMI) of over 40 OR has a BMI of over 35) with a life-threatening co-morbid disease such as:
- Congestive Heart Failure
- Metabolic Syndrome
- Coronary Artery Disease
- Cardiomyopathy caused by obesity
- The patient, in the 12 months prior to the surgery, has to have:
- Completed a weight loss program for at least six consecutive months
- Participated in a surgery preparation program to enhance results and lower risk of complications after the procedure. Your surgeon will typically have these available.
- Undergone pre-operative psychological evaluation and understands the impacts of weight loss surgery
- The patient should have a letter of recommendation from his/her primary doctor.
- The bariatric surgeon should submit the proper paperwork for approval. The bariatric surgery request form can be found here.
You can see a full list of co-morbidities here. The patient has to fulfill all of the criteria listed above to be approved for bariatric surgery.
Types of Weight Loss Surgeries Covered By Horizon Blue Cross Blue Shield of New Jersey
Horizon Blue Cross Blue Shield New Jersey covers the following weight loss surgeries:
- Biliopancreatic Diversion with Duodenal Switch
- Laparoscopic Adjustable Gastric Banding
- Gastric Bypass with Short-Limb Roux en Y anastamosis
- Gastric Bypass with Long-Limb Roux en Y anastamosis
- Vertical Banded Gastroplasty
- Sleeve Gastrectomy
These procedures are considered medically necessary for treating morbid obesity.
Procedures Excluded From Coverage
Mini-gastric bypass, gastric plication and other surgeries not listed above are considered experimental and not covered.
Is A Second Weight Loss Surgery Covered If Lap Band Doesn’t Work?
Coverage for a second weight loss surgery is decided on a case to case basis. The medical director at Horizon Blue Cross Blue Shield New Jersey will analyze the application. Important information required for making a decision include the patient’s BMI and documentation proving the procedure failed the first time. The criteria for approval for a second weight loss surgery are:
- Proof of compliance with the postoperative dietary, exercise and lifestyle recommendations
- Weight regain or inadequate (<50%) weight loss
- Dilation of the gastric pouch or any other technical failure
Revisions are also decided on a case to case basis. The revision has to be considered medically necessary in order to be covered. The criteria for approving revisions are the same as that for repeat weight loss surgeries.
Does Horizon Blue Cross Blue Shield Require A Center Of Excellence?
Blue Cross policies require a patient to have surgery at a Blue Distinction Center. Below is a list of approved centers in New Jersey for bariatric surgery:
- AtlantiCare Regional Medical Center
- CentraState Medical Center
- Lourdes Medical Center of Burlington County
- Our Lady of Lourdes Medical Center
Do I Have To Use An In-Network Bariatric Surgeon?
Using an in-network surgeon is not mandatory under most Blue Cross policies, but it results in lower out of pocket costs. Your surgery may have to be performed at a Blue Distinction Center. It’s recommended to call one of the centers listed above and ask for a list of approved surgeons.
Blue Cross New Jersey Horizon Contact Info to Inquire About Surgery
Call Horizon Blue Cross Blue Shield New Jersey at 1-800-355-BLUE or visit their website to inquire about weight loss surgery.