Does Anthem Blue Cross (BCBS) Georgia Cover Bariatric Surgery?
One of the first questions our Georgia patients ask is whether their insurance will cover bariatric surgery and, if so, what their out-of-pocket expenses will be.
Anthem Blue Cross Georgia is the largest health insurer in the state, with over 1,000,000 policies and over 30% market share. As a result, Blue Cross is often at the forefront of insurance company policy changes as they relate to coverage of bariatric surgery and other procedures.
The most important thing to understand about any health insurance policy is that there are also specific exclusions beyond the list of covered procedures. Bariatric surgery is a common exclusion, and a read through your policy documents and calling Anthem Blue Cross Georgia can give you clarity on your specific policy. We can also assist you in verifying your benefits, but you must speak to your insurance to clarify any questions you may have.
Does My Employer’s Policy Cover Bariatric Surgery?
Your employer may have an Anthem Blue Cross policy, but they may specifically elect to exclude bariatric surgery as a covered service. This is usually due to cost considerations. So be sure to speak to your employer or HR department to see your coverage.
What are the Anthem BC Georgia Criteria for Coverage?
If your BCBS insurance policy covers bariatric surgery, you must meet particular criteria to be eligible for coverage and receive pre-approval for surgery. These criteria can vary dramatically between insurance companies and even between policies. Hence, it is crucial that you understand your specific policy terms and only use the below as a guide.
- BMI. Your Body Mass Index must be 35 or greater with two comorbidities or 40 or greater regardless of comorbidities
- Pre-op weight loss programs. Most policies require participation in a weight loss program before pre-approval for weight loss surgery. This program will consist of diet and lifestyle changes and may include medication management
- Comorbidities. If your BMI is under 40, you will have to show that you also suffer from diseases associated with morbid obesity. Qualifying comorbidities include high blood pressure, high cholesterol, sleep apnea, osteoarthritis, type 2 diabetes, and more
- History of failed diet and exercise. Your insurance company will expect you to provide proof of failure in diet and exercise programs. The amount of documentation they require may vary, but be prepared to prove attempts to lose weight
- Medical necessity. They may also need a letter from your primary care physician. This letter shows that bariatric surgery is medically necessary in their medical opinion. We will also provide an appropriate letter
- Center of Excellence. Surgery must be performed at a Center of Excellence facility
- Nutritional and psychological evaluation as well as other pre-op testing
What Procedures Are Covered?
Procedures considered experimental like the Mini Bypass will not be covered. Band fills are covered if you had a gastric band using your insurance, but not for cash pay. The gastric balloon is not yet covered by insurance, and we do not offer it for several reasons.
Are Revisions Covered?
As is the case with most insurers in the United States, revisions are covered on a case-by-case basis. Typically, coverage is offered if the patient experiences a complication after surgery. Revisions or conversions due to a lack of weight loss may be covered if the patient still meets the criteria and is compliant with their postoperative lifestyle. Weight-related revision procedures are usually covered two or more years after the primary surgery and are based on the weight lost.
What If I Do Not Receive Pre Approval?
We work closely with you and Anthem Blue Cross Georgia to ensure that the preapproval process includes all of the required criteria for them to approve you. As a result, if the pre-approval does not come through, it is often a clerical error that can be fixed easily. We encourage our patients to carefully review their submissions to ensure criteria are met, and documentation is presented in the format that the insurance company expects.
Does A Pre-approval Guarantee Coverage?
Pre-approval for coverage does not automatically guarantee payment. There are various reasons that the insurance company can deny your claim. Once again, many of these are administrative mistakes that are easily fixed. You can appeal your denial to the insurance company should resubmitting your claim fail once again.
The insurance process can be complicated, especially with a procedure such as bariatric surgery. The insurance company wants to verify that the procedure is necessary. Still, there is a gray area, and we help you navigate those intricacies and questions to make the process as easy as possible. The first step is to inquire about your eligibility for bariatric surgery, which you can do by contacting our office or attending one of our in-person seminars or the online seminar available 24/7.
Anthem Blue Cross Georgia can be contacted via email or telephone. You may need to call a different number depending on your plan type. Please follow this link to see all contact options: https://www.anthem.com/contact-us/georgia/