Does Blue Cross Blue Shield Arizona (BCBSAZ) Cover Bariatric Surgery?
Blue Cross Blue Shield of Arizona is the largest health insurance in the state of Arizona and offers a wide variety of PPO and HMO policies. As with most insurance companies, they have a relatively straightforward, but stringent set of criteria for covering bariatric surgery. However, bariatric surgical coverage varies between policies and even if someone you know has bariatric coverage with BCBS Arizona, that does not mean that your policy will. Therefore, the first step is to speak to BCBS to understand a) whether you have coverage for bariatric surgery and b) what the requirements are for coverage.
General requirements for coverage of bariatric surgery
Please note that the requirements below are not comprehensive and may change. Always speak to Blue Cross Blue Shield of Arizona or our office to understand the most up-to-date requirements for coverage. Blue Cross Blue Shield Arizona will have a number of general requirements. Some may be specific to your medical situation. In general, the following are necessary for coverage:
- A BMI of 35 or over with comorbidities of obesity including type 2 diabetes, high cholesterol, high blood pressure or obstructive sleep apnea. Or a BMI of 40 or over regardless of comorbidities associated with obesity.
- Medical necessity. This is a general insurance term requiring that the insurance company verify bariatric surgery is necessary for health and medical reasons and not just a way for a patient to lose weight. We prove medical necessity by collaborating with your primary care physician and other specialists that care for you, to show that bariatric surgery is the best option for regaining your health.
- A proven history of weight loss attempts. The BCBS AZ will want to know that you have tried to lose weight through other means before you have bariatric surgery. This may be commercial diets, weight loss programs and even physician supervised weight loss. We can help you compile the evidence needed to satisfy this requirement including proof of a prior diagnosis of morbid obesity.
- Medical weight loss program. Blue Cross Blue Shield of Arizona will stipulate the length of time, usually 8 weeks or more, that you must undergo medical (non-surgical) weight loss program.
While completing all of the steps above and obtaining a preauthorization gets us most of the way there, it does not guarantee coverage. There are occasions in which clerical errors cause a rejection of coverage. These are usually easily rectified, and you should not panic if you receive a denial. We will work with you to correct errors and overturn that denial through an appeal. Learn more about what to do if your bariatric surgery coverage is denied.
Virtually all Blue Cross Blue Shield of Arizona bariatric surgery policies have a number of costs that a patient will incur. We will help you estimate these costs before surgery, but they can be somewhat confusing. The sooner you understand your financial obligations, the less you will have to worry about throughout the process. You will likely be responsible for the following:
Deductible. This is the patient responsibility prior to insurance starting to cover your care. Early on in the year, your deductible will likely be higher. But as you contribute to your deductible through other medical procedures and doctor’s visits, the deductible will progressively get lower.
Co-insurance. Once you have met your deductible, you will be responsible for a percentage of the cost of surgery. The coinsurance will depend on your policy and may range from zero to 50% for most policies.
Copayments. This is typically a fixed fee set by the nature of the visit. Your explanation of benefits will give you an idea of your copayments, but we can also help estimate what your payments will be throughout the process.
Maximum out of pocket expense. Each year, your policy limits your out-of-pocket expense. If you reach that limit, your insurance is obligated to pay for any covered services beyond that point. Therefore, if you have had a number of medical procedures early on in the year, you may have a lower out of pocket expense later on in the year.
It is worth noting that policy limits are reset every calendar year. Therefore, ideally, if you have used many of your benefits over the course of the year, having your procedure before the end of the year may be beneficial, from a financial standpoint. Since bariatric surgery and Blue Cross Blue Shield of Arizona approval is a relatively lengthy process, we suggest starting early on and being ready.
Does BCBS AZ Cover Revision Surgery
If you have had bariatric surgery and require a revision due to weight regain, Blue Cross Blue shield of Arizona may cover the procedure. BCBS approves revision procedures on a case-by-case basis and based on medical necessity. The most common revisions include a Lap-Band to Sleeve, Lap-Band to Bypass or even a Sleeve to Bypass.