Does Anthem Blue Cross (BCBS) Georgia Cover Bariatric Surgery?
One of the first questions that our Georgia patients ask is whether their insurance will cover bariatric surgery and if so, what will their out-of-pocket expense 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 beyond the list of covered procedures, there are also specific exclusions. 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 it is important that you 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 the HR department to see what coverage you may have.
What are the Anthem BC Georgia Criteria for Coverage?
If your BCBS insurance policy covers bariatric surgery, you will be required to meet a certain set of criteria to be eligible for coverage and receive a pre approval for surgery. These criteria can vary dramatically between insurance companies and even between policies, so it is important that you understand your specific policy terms and only to 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 change 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 require a letter from your primary care physician. This letter shows that in their medical opinion, bariatric surgery is medically necessary. 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 a number of reasons.
Are Revisions Covered?
Revisions are covered on a case by case basis as is the case with most insurers in the United States. 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 criteria and was compliant in their postoperative lifestyle. Weight-related revision procedures are usually covered 2 or more years after the primary surgery and are based on the amount of 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 all of our patients to carefully review their submission to ensure criteria are met and documentation is presented in the format that the insurance company expects.
Does A Preapproval Mean Guarantee Coverage?
Preapproval 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 have the option to 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, but 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 by attending one of our in-person seminars or the online seminar that is available 24/7.
Anthem Blue Cross Georgia can be contacted via email or telephone. You may need to call a different number depending on the type of plan you have. Please follow this link to see all contact options: https://www.anthem.com/contact-us/georgia/