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BCBS of Alabama Bariatric Surgery: Requirements, Coverage, Denials

Does Blue Cross Blue Shield of Alabama (BCBS) cover bariatric surgery? Learn about BCBS of Alabama’s requirements for weight-loss surgery.

Weight loss is only one of the many health benefits of Bariatric surgery, but to consider the weight loss successful, patients must keep the weight off for a minimum of five years with the help of proper diet and regular exercise. Many who have sustained their weight loss through Bariatric surgery have reported a significant improvement in their overall health and lifestyle.

Blue Cross Blue Shield of Alabama has helped individuals struggling with obesity who have tried various weight loss methods but haven’t been successful on their own. The following are three types of weight loss procedures that are covered by BCBS Alabama.

Gastric banding, Lap Banding and Realize Band – Gastric banding involve fitting an adjustable silicone band around the upper part of the stomach where the band restricts the amount of food and caloric intake, consequently allowing patients to lose up to 45% of their weight.

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. 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.

Laparoscopic Gastric Bypass – This procedure is performed laparoscopically, an approach that is less invasive than open incision surgery, where the surgeon staples the top portion of the stomach to separate it from the bottom part to create a small stomach pouch that restricts food intake the number of calories and nutrients the body absorbs.

Open Gastric Bypass Surgery – This procedure is rare and only performed under particular medical circumstances. It requires abdominal incisions of up to ten inches for patients with extremely high BMI, those with certain health conditions that make laparoscopic surgery risky, or those with significant scar tissue from other abdominal medicine that may prevent access to the surgical area.

Preoperative Requirements

  • Patients must be above 18 years with a BMI of 40 and above or a BMI of 35 with or greater with co-morbid conditions such as cardiovascular disease, diabetes, or severe obstructive sleep apnea
  • Provide documentation to prove that they are diagnosed as morbidly obese, and they are unable to achieve a healthy body weight for a sustained period, even through medically supervised dieting
  • Must not smoke eight weeks before surgery

Approval Process

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. It is at this point that an insurance verification coverage process is conducted as well as pre-operative testing. You will also be asked to sign a commitment form that requires to be on a medically supervised pre-operative diet as well as attend a support group before your surgery.

Surgery Denial

Even when a policy covers weight loss surgery for qualifying patients, some situations may lead to a denial such as:

  • Not passing a psychological exam
  • Not meeting the specified MBI criteria of either 40 and above or 35 or higher with one or more comorbid conditions
  • Not going to an approved nutritionist

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.

To contact Blue Cross Blue Shield of Alabama, you can either log into their official website https://www.bcbsal.org/web/index.html, use the telephone numbers on the back of your BCBSA ID card or call 1-888-267-2955 for family and individual services.