*GP( @ r UQ T9 *GP( @ r UQ T9 Blue Cross Michigan does not cover procedures considered investigational. Repeat surgical procedures for revision or conversion to another surgical procedure may be considered medically necessary when the initial bariatric surgery was medically necessary (and the individual continues to meet all the medical necessity criteria for bariatric surgery);andwhenANYONEof the following criteria is met: Internal Medical Policy Committee 11-29-2022 Coding update - December 06, 2022, Fargo (Headquarters) *GP( @ r UQ T9 *GP( @ r UQ T9 Weight Loss Surgery Insurance Appeal Letter & The Appeals Process, Recovery from Gastric Sleeve What to Expect from Day 1. endobj *GP( @ r UQ T9 The individual's understanding of the procedure and ability to participate and comply with life-long follow-up and the life-style changes (e.g., changes in dietary habits, and beginning an exercise program) are necessary to the success of the procedure. Diagnosis of Morbid obesity, defined as. 16 0 obj Forms | Providers | BlueCare Tennessee - BCBST PDF BCBSM Medicare Advantage PPO Weight Loss Surgery Enhanced Benefit Section 3. 9 0 obj Read information on bariatric procedures, guides, find a surgeon and more. One option is Adobe Reader which has a built-in reader. Reimbursement will be 75% of the fee schedule . 13 0 obj 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. *GP( @ r UQ T9 2022 Bariatric Surgery Coverage Announcements Summary . Policy: 7.01.47 Effective Date: Nov. 1, 2022 Last Revised: Jan. 1, 2023 Replaces: 7.01.47 RELATED MEDICAL POLICIES: 2.01.38 Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease 7.01.522 Gastric Electrical Stimulation . NOTICE: This policy contains information which is clinical in nature. Bariatric surgery should be performed in appropriately selected individuals 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. endobj *GP( @ r UQ T9 [oH:kv=(@me_Wu C w/n7}3N$*hX|! Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association, serving residents and business in North Dakota. Blue Cross Blue Shield of North Carolina NC 3,700,000 4/1/2021 link X X X Anthem Blue Cross Blue Shield GA 3,600,000 8/13/2020 link X X CareFirst Blue Cross Blue Shield DC, MD, northern VA 3,500,000 7/1/2020 link X X (6 consecutive months w/in past 2 years) Anthem Blue Cross Blue Shield OH 3,400,000 8/13/2020 link X X @h23Begj!b4ZJ2}Y*bPc6d 5d 05dD/Br,Fsr#0Yi^kRsTCx aEt! Greater than or equal to 18 years; or b. So we are happy to report that manyAnthem BCBS policies cover weight loss surgery. Torrance Bariatric Institute provides expert weight loss procedures for patients looking for bariatric surgery in Torrance and surrounding areas. *GP( @ r UQ T9 Coronary artery disease. The site may also contain non-Medicare related information. endobj Psychiatric Residential Treatment Request Form. Centers for Bariatric Surgery. <> Bariatric procedures not meeting the criteria as indicated in this policy are considered not medically necessary. According to Blue Cross/Blue Shield of California Medically Necessary. *GP( @ r UQ T9 These centers have lower complication rates and fewer readmissions. The following bariatric procedures may be considered medically necessary for the surgical treatment of morbid obesity whenALLof the selection criteria are met. *GP( @ r UQ T9 Renew Illinois Individual, Family & Medicaid Health Insurance, Blue Cross Community MMAI (Medicare-Medicaid Plan), Illinois Health Plan Tiered Prescription Drug Lists, Making Your Health Insurance Work For You, Prescription Drug Changes and Pharmacy Information, Machine Readable Files for Transparency in Coverage. <> One option is Adobe Reader which has a built-in reader. The individual is morbidly obese and is at least 18 years of age. stream *GP( @ r UQ T9 <> stream *GP( @ r UQ T9 hbbd```b``~"gHR ,,"G3`q+0%XW8gC3kIG vD2u 6 Hf`bd`20R x g TTY users can call 1-877-486-2048. However, your deductible and out of pocket costs may be significantly lower if you do. The eligible bariatric surgical procedures listed above unless otherwise specified are covered for individuals under the age of 18 years when they meetALLof the following criteria: If the adolescent does not meetALLof the adolescent selection criteria for bariatric surgery, the procedure will be denied as not medically necessary. <>/Font<>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> of the adolescent selection criteria for bariatric surgery, the procedure will be denied as not medically necessary. PDF FEP Blue Focus Prior Approval List - Premera Blue Cross So, to find out if your policy includes coverage, please talk directly to Blue Cross Michigan. The individual's medical record documentation should indicate that all psychosocial issues have been identified and addressed; Psychological evaluation documentation must be within the last year; Attainment or near-attainment of physiologic/skeletal maturity at approximately, age 13 in girls and 15 for boys. Here you will find information for assessing coverage options, guidelines for clinical utilization management, practice policies, the provider manual and support for delivering benefits to our members. *GP( @ r UQ T9 *GP( @ r UQ T9 a Body Mass Index (BMI) greater than 40. <> Our Philosophy; . Do I Need To Attend? *GP( @ r UQ T9 Please contact BCBS of Michigan directly to find out if they offer coverage for a second procedure. To view this file, you may need to install a PDF reader program. Blue Cross and Blue Shield's Federal Employee Program Benefit Plans Brochures and Forms Webpage . ZIc$"NmZ;} AdN5N`]_c[K2~3[p'X9 YM"]0*=|. AZBlue - Medical Policies 2 0 obj there are documented recurrent or chronic rashes, infections, cellulitis, or non-healing ulcers, that do . rvYWDgg!MxV Liq V8 K+%w\R,XXXYY&1]yxh~C%k.2 MeOaLd9 sG@Afd`}w U *GP( @ r UQ T9 endobj Unsure which surgery is right for you? All rights reserved. This is true only if youve had a previous adjustable gastric banding procedure that met all of the criteria laid out for that procedure. *GP( @ r UQ T9 *GP( @ r UQ T9 The individual should have documented failure to respond to conservative measures for weight reduction prior to consideration of bariatric surgery, and these attempts should be reviewed by the practitioner prior to seeking approval for the surgical procedure. Gastric Banding including the Lap Band and Realize Band, Duodenal Switch also known as Biliopancreatic Diversion, Any other experimental weight loss procedure, The patient continues to meet all the medical necessity criteria for bariatric surgery, and, There must be documentation that the patient was compliant with the original post-operative dietary and exercise program, and. of the selection criteria for bariatric surgery, the procedure will be denied as not medically necessary. *GP( @ r UQ T9 Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. To find out which services are covered under your policy at any facility, please call the customer service phone number on the back of your Blue Cross and Blue Shield of Texas member ID card. Blue Cross Blue Shield Association. 500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM Long-Limb Gastric Bypass (le, >150 cm) (CPT code 43847 - Gastric restrictive procedure with External link You are leaving this website/app (site). Body Mass Index (BMI) of 40 or greater OR. *GP( @ r UQ T9 Internal Medical Policy Committee 1-20-2022 Revision with coding updates; Internal Medical Policy Committee 11-29-2022 Coding update - Medicaids Criteria for Weight Loss Surgery Coverage. The following are three types of weight loss procedures that are covered by BCBS Alabama. It is important to know that your employer can typically opt-out of weight loss surgery insurance coverage for their employees policies. Blue Cross of California is the trade name for Anthem BCBS so your criteria for weight loss surgery will be the same as it is here. *GP( @ r UQ T9 *GP( @ r UQ T9 and Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association, PDF File is in portable document format (PDF). QiP^0#jfc~%M/8 2E .vP[mc~9} This policy provides direction on Blue Cross Blue Shield of North Dakota (BCBSND) reimbursement for global surgical package and subsequent services provided within the global surgery days. Enteric fistula that does not close with bowel rest and nutritional support; Gastrogastric fistula associated with ulcers, gastroesophageal reflux disease (GERD) and weight gain; Disruption/anastomotic leakage of a suture/staple line; Band intolerance with obstructive symptoms (e.g. Blue Cross Requirements for Weight Loss Surgery Origination: Last Review: Description of Procedure or Service . Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. *GP( @ r UQ T9 Repeat or Revised Bariatric Surgical Procedures. Bariatric Surgery Which Procedure Is Best? or 100% over ideal weight or a body mass index (BMI) of at least 40 or a BMI of 35 with comorbidities. *GP( @ r UQ T9 stream If this is the case and you find a second surgery or procedure is needed, you might find that Blue Cross Blue Shield does provide coverage for a second surgery as long as you followed post-operative instructions and made lifestyle changes for success as well as turned to the bariatric surgeon and other sources for additional help. BCBS New York Excellus Weight Loss Surgery Kaiser Permanente Covers Weight Loss Surgery. of the selection criteria are met. *GP( @ r UQ T9 patient education. endstream endobj startxref xVk@~7=nBvcBP`k2OMp}Nn%04)X?P0B3MHJZ+cHf\|&r4\1oZ) "M 2. endobj <> This new site may be offered by a vendor or an independent third party. Learn about BCBS of Alabama's requirements for weight-loss surgery. =-]U6>(-Is[i5}{u?B}X* 4510 13th Ave. S. or 100% over ideal weight; Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite concurrent use of three (3) anti-hypertensive agents of different classes); Cardiovascular heart disease (with objective documentation by exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure or prior myocardial infarction); Coronary heart disease (with objective documentation (by exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, heart failure, or prior myocardial infarction); Hyperlipidemia (above 30mg/dl above guideline-directed goal) on maximum doses of monotherapy; Diabetes mellitus type II; with glycosylated hemoglobin (HbA1C) above 8.0 percent on one (1) or more medications; Obstructive sleep apnea (OSA); (diagnosed by polysomnography showing apnea-hypopnea index of 15 events per hour or more); Pickwickian syndrome (a combination of OSA and OHS); Nonalcoholic fatty liver disease (NAFLD); The individual must have documented failure to respond to conservative measures for weight reduction for a period of at least six (6) consecutive months, prior to consideration of bariatric surgery, and these attempts should be reviewed by the practitioner prior to seeking approval for the surgical procedure. Even when a policy covers weight loss surgery for qualifying patients, some situations may lead to a denial such as: You or your doctor can write a letter of appeal to the insurance company to appeal, you must, however, provide documentation for all the criteria listed in the policy as well as those from your previous communications with your insurance company about the surgery. Will Your Stomach Stretch after Gastric Sleeve Surgery? endobj *GP(:&. IMPORTANT REMINDER . SKYGEN USA administers dental services for Horizon NJ Health members. During the Realize Band procedure, two devices are implanted during surgery, and the surgeon injects saline into the port to tighten or loosen the band based on weight loss goal and physical reactions to the operation. Laparoscopic adjustable gastric banding using an FDA-approved adjustable gastric band is a second-tier procedure that shouldONLYbe performed when extenuating circumstances exist. 6Nale{Aq;7Qy=1(tg?fd``{ X'@``} QT` *GP( @ r UQ T9 *GP( @ r UQ T9 Full coverage for a weight loss surgery procedure will be provided to a patient with a Body Mass Index (BMI) over 40. Representatives are available 24 hours a day, seven days a week. vomiting, esophageal spasm); Band slippage and/or prolapse that cannot be corrected with manipulation or adjustment; Stricture/stenosis with dysphagia, solid food intolerance and/or severe reflux; Non-absorption resulting in hypocalcemia or malnutrition; Weight loss of 20 percent or more below ideal body weight. *GP( @ r UQ T9 Effective January 01, 2023, Internal Medical Policy Committee 3-23-2023 Revision - Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. O stream Gastric Sleeve Completed Tour; Gastric Sleeve Expecting Weights Loss, End; Average Cost of Gastric Sleeve Surgery; Abdominal Sleeve: After Surgery Results and Selling; Gastric Hose Surgery: Recovery Time; Gastric Sleeve Pre-Op Diet; Duodenal Sleeve Post-Op Diet Guide; Gastric Sleeve . However, coverage and payment for these services depends on the type of provider submitting the claim, the procedure/service and diagnosis codes submitted, and the patient's contract with Blue Cross. 0 This site complies with the HONcode standard for trustworthy health information: Verify here. *GP( @ r UQ T9 If you have surgery, some private Medicare Supplement plans might cover some out-of-pocket costs not covered under Original Medicare pays, such as . Morbid obesity is further defined as a condition of consistent and uncontrollable weight gain that is characterized by a weight which is at least 100 lbs. *GP( @ r UQ T9 endobj Request Out of Network Benefits. Individuals should have documented failure to respond to conservative measures for weight reduction prior to consideration of bariatric surgery, and these attempts should be reviewed by the practitioner prior to seeking approval for the surgical procedure. endobj The duration of the weight loss program should have been at least twelve consecutive months. *GP( @ r UQ T9 Location: MO. Policies, Guidelines & Manuals. *GP( @ r UQ T9 Bariatric Surgery | BCBSND Primary Care Physician's Letter. The Lap-Band procedure also uses adjustable silicone band placed around the top part of the stomach to restrict the amount of food your stomach can hold. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically. Learn more about weight loss surgery at Rocky Mountain Associated Physicians www.RMAP.com (801) 268-3800. *GP( @ r UQ T9 They are: This list is not comprehensive. Yes, weight loss surgery must be done at a. A psychological evaluation must be performed by a licensed mental health care professional, and the individual must be recommended for bariatric surgery. InterQual criteria is used to evaluate whether a medical procedure or equipment . The individual's medical record documentation should indicate that all psychosocial issues have been identified and addressed; The individual must be able to show decisional capacity and maturity in the psychological evaluation and provide informed assent for surgical management; The individual must be capable and willing to adhere to nutritional guidelines postoperatively; The individual must have a supportive and committed family environment; Selection criteria is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. Please note that not all policies include coverage. Covered Diagnosis Codes for Procedure Codes: 43644, 43770, 43775, 43843, 43846, and S2083, Covered Diagnosis Codes for Procedure Code: 43845, Internal Medical Policy Committee 3-16-2020 Revision, Internal Medical Policy Committee 11-19-2020 Revision, Internal Medical Policy Committee 11-23-2021 Revision. Weight loss surgery is an effective treatment for morbid obesity. *GP( @ r UQ T9 Most PDF readers are a free download. Morbid obesity is further defined as a condition of . Anthems can be contacted at1-866-293-2892. Open Gastric Bypass Surgery This procedure is rare and only performed under particular medical circumstances. endstream *GP( @ r UQ T9 endobj Bariatric Surgery | Blue Cross and Blue Shield of Oklahoma - BCBSOK Blue Distinction Centers for Bariatric Surgery, along with the Blue Distinction Centers for Cardiac Care, Blue Distinction Centers for Knee and Hip Replacement, Blue Distinction Centers for Maternity Care, Blue Distinction Centers for Spine Surgery, Blue Distinction Centers for Substance Use Treatment and Recovery and Blue Distinction Centers for Transplants are a key part of our efforts to work with doctors and facilities to improve the overall quality, and resulting affordability of specialty care. endstream *GP( @ r UQ T9 %%EOF 1238 0 obj <>stream Bariatric Journal is the leading bariatric surgery resource site for patients. Returning Shopper? No. <> *GP( @ r UQ T9 *GP( @ r UQ T9 *GP( @ r UQ T9 We recommend that you only use this publication in conjunction with the current year's health premium rate schedule and EOCs. Yes, some Blue Cross Blue Shield plans may not cover bariatric surgery. The Pouch Reset Losing Weight After Weight Regain, Expected Weight Loss From Gastric Sleeve Surgery Calculator, Recovery From Gastric Sleeve What To Expect From Day 1, Before And After Your Gastric Balloon [Complete Guide], 5 Ways to Prevent Stretching Your Stomach After Gastric Bypass. Sometimes you will need to Read more Coverage Policy Manual - Arkansas Blue Cross and Blue Shield All rights . Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. Review: Prosper Healthcare Lending Should You Choose it for Bariatric Surgery Financing? Blue Cross and Blue Shield Service Benefit Plan Surgical Procedures FBF22.05b.1 Page 3 of 5 1/1/2020 Benefits for the surgical treatment of morbid obesity, performed on an inpatient or outpatient basis, are subject to the pre-surgical requirements listed below. View Medical Policies | Excellus BlueCross BlueShield *GP( @ r UQ T9 The Center of Excellence should be certified by the American College of Surgeons as a level 1 bariatric surgery center. <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 960 540] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> *GP( @ r UQ T9 *GP( @ r UQ T9 3 0 obj The letter should also state that the physician has evaluated the patients mental condition and he/she is fully prepared for the surgery. An Independent Licensee of the Blue Cross and Blue Shield Association. Skip to content. ALL *GP( @ r UQ T9 Obesity is an increase in body weight beyond the limitation of skeletal and physical requirements, as a result of excessive accumulation of fat in the body. endobj ;.SovgPmc0u Ut9p+o1)ddT,c2MXy`PO;V kFXn^n1=u C5UL|efWaXenAFKua{ %,U(>t~;xL*[lMfl/$"Rg: >ArMT+&9!-Aa(=Xj _i5j)tpJh$D':uZ;yz.1KLLF The items below are the minimum necessary for approval of your weight loss surgery. A new Global Period will not apply to a procedure meeting these requirements and reported with modifier 78. Complications can include but are not limited to fistula, obstruction or disruption of a suture/staple line. PDF Bariatric Surgery Selection Criteria - Blue Cross Blue Shield Association *GP( @ r UQ T9 4 0 obj *GP( @ r UQ T9 Which Bariatric Surgery is Best? However, since Blue Cross Michigan requires a Center of Excellence, using an in-network surgeon is recommended. The site may also contain non-Medicare related information. Access Your Payment Options. *GP( @ r UQ T9 "Dental necessity" or "dentally necessary" means or describes a dental service that a dental care provider, exercising prudent clinical judgment, would provide to a covered person for the purpose of evaluating, diagnosing or treating a dental illness . PDF 379 Medical and Surgical Management of Obesity and Anorexiants Blue Distinction Criteria. ANYONE 6 0 obj Understanding Weight-Loss Surgery: Is it for you? 1/5/2022 X Blue Cross Blue Shield of North Carolina 2,239,860 NC 12/2021 link 1/5/2022 X Medica Health 831,299 MN, NE, WI, IA, ND, SD 11/22/2021 link . 2022 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option Section 5. Benotti PN, Still CD, Wood GC et al. However, there is a lack of evidence on the optimal timing, intensity and duration of nonsurgical attempts at weight loss, and whether a medical weight loss program immediately preceding surgery improves outcomes; The individual must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for bariatric surgery. . Referral for Applied Behavioral Analysis (ABA) Assessment, Initiation and Continuation Request Form for Applied Behavior Analysis. Pre-Cert/Pre-Auth (In-Network) - CareFirst Does Blue Cross Blue Shield of Alabama (BCBS) cover bariatric surgery? If you are planning on having any of the above weight loss procedures and you meet the pre-approval requirements, you should schedule an initial meeting with your Bariatric surgeon of choice who will give you an overview of the process as he/she reviews your health history to confirm eligibility. Posted February 24, 2015. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. Blue Distinction Centers and Blue Distinction Centers+ for Bariatric Surgery offer a full range of bariatric surgery care, including: These centers have lower complication rates and fewer readmissions. *GP( @ r UQ T9 *GP( @ r UQ T9 "Our comprehensive program helps patients [] *GP( @ r UQ T9 Page 18. outpatient follow-up. *GP( @ r UQ T9 Bariatric surgery is performed to treat morbid . 773 0 obj <>/Filter/FlateDecode/ID[<675B09CE55CCC14F9AD95E27B755F731>]/Index[748 42]/Info 747 0 R/Length 117/Prev 507134/Root 749 0 R/Size 790/Type/XRef/W[1 3 1]>>stream Copyright 2022 Bariatric Journal, All Rights Reserved. *GP( @ r UQ T9 Fargo, N.D., 58121. *GP( @ r UQ T9 File Name: bariatric_ surgery 5/1983 . Typically, if you paid cash for the procedure ongoing lap band fills will not be covered by insurance. We're committed to supporting you in providing quality care and services to the members in our network. of the following criteria: If the adolescent does not meet BCBS of Texas Criteria for Weight Loss United Healthcares Criteria For Weight Loss Surgery Coverage, Anthem BCBS Requirements for Weight Loss Surgery, Medicares Criteria For Weight Loss Surgery Coverage. a BMI of 35 or greater with at least 2 comorbidities. 2 0 obj Anthems full policy on weight loss surgery insurance coverage is no longer available online. *GP( @ r UQ T9 blue shield bariatric surgery requirements - Blucross Blueshield 2022 <> Based on our data, the target fair price for a laparoscopic hysterectomy is $12,250, whether you have health insurance or not. Blue Distinction Centers for Bariatric Surgery, along with the Blue Distinction Centers for Cardiac Care, Blue Distinction Centers for Knee and Hip Replacement, Blue Distinction Centers for Maternity Care, Blue Distinction Centers for Spine Surgery, Blue Distinction Centers for Substance Use Treatment and Recovery and Blue Distinction Centers for Transplants are a key part of our efforts to work with doctors and facilities to improve the overall quality, and resulting affordability of specialty care. Morbid *GP( @ r UQ T9 Bariatric surgery (any procedure) for patients with a BMI < 35 kg/m 2 including but not limited to solely as a cure for type 2 diabetes mellitus; . F(wG((|1]) Bariatric Surgery | Blue Cross and Blue Shield of Illinois - BCBSIL PDF Bariatric Surgery Selection Criteria - Blue Cross Blue Shield Association Morbid obesity is defined as a condition of consistent and uncontrollable weight gain that is characterized by. ,_*:1Ch_WpK3R6UYo gD_){6^9V0ljRoZY=;~lov'xmv'}y3-{lZjUTi:hnS: ]}}_v$j&m.~.?NIcWX*}pO=-f)/QeQ7vuT'UJ_\}Sj}NU~WOT}J"^ Surgical repair to correct perioperative or late chronic complications of a bariatric procedure may be considered medically necessary when there is documentation of a surgical complication related to the perioperative or late chronic complications of a bariatric procedure. Bariatric surgery in patients with diabetes and body mass index less than 35 kg/m 2.
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