| Aetna |
Per Clinical Policy Bulletin #0157, patients require presence of severe obesity for at least 2 years; physician-supervised nutrition and exercise program of at least 3 consecutive months, documented in medical record, behavior modification treatment and a psych evaluation if medically indicated. |
Not Covered |
Aetna Bariatric Surgery Coverage |
| Anthem Blue Cross |
Per Clinical Policy Bulletin SURG.00024, insurance requires Attachment A to be filled out which requires psych and one diet consult. |
Not Covered |
Anthem Blue Cross Bariatric Surgery Coverage |
| Blue Cross Federal |
Patient must have BMI over 40 or BMI 35-40 with treated, uncontrolled co-morbid condition. Sleeve is covered. |
Covered |
Blue Cross Federal Bariatric Surgery Coverage |
| Blue Cross National CareFirst |
Per Policy Bulletin 7.01.036, insurance requires psych clearance and 6 month diet (or two 3 month diets). Gastric Sleeve is covered. |
Not Covered |
Blue Cross National Care First Obesity Coverage |
| Blue Cross of Alabama |
Per Policy Bulletin 053, insurance requires 6 months physician-supervised program consisting of nutrition and increased physical activity, three years medically documented morbid obesity and H & P by bariatric surgeon. Participation in programs such as Weight Watchers, LA Weight Loss, Eat Right, with madical supervision and documentation. Sleeve is investigational and not covered. |
Not Covered |
Blue Cross Alabama Bariatric Surgery Coverage |
| Blue Cross of Arkansas |
Per Policy Bulletin 1998118, insurance requires BMI over 36 and failed structured weight loss program. Gastric Sleeve is covered if BMI >60 with cardiac or pulmonary co-morbidities. |
Not Covered |
Blue Cross Arkansas Website |
| Blue Cross of California |
The first treatment of morbid obesity is dietary and lifestyle changes. Bariatric surgery should be reserved for patients for whom all other methods of treatment have failed. Blue Shield of California pre-authorization for bariatric surgery and requires that PPO members living in select counties in Southern California use only designated providers. Gastric Sleeve is investigational and not covered. |
Not Covered |
Blue Cross California Bariatric Surgery Coverage |
| Blue Cross Blue Shield of Delaware |
Insurance requires LOMN, cardiac, pulmonary and psych clearance and sleep apnea work-up. |
N/A |
BCBS Delaware Health Insurance Plans |
| Blue Cross Blue Shield of Florida |
Per Policy Bulletin 02-40000-10, insurance requires five-year history, 6 month diet, psych evaluation, and TSH showing no endocrine disorders. Sleeve is covered. |
N/A |
BCBS Florida Site |
| Blue Cross Blue Shield of Georgia |
Per Policy Bulletin SURG.00024, insurance requires one diet consult with history of previous weight loss attempts, psych evaluation, compliance letter from patient, treatment plan, and attachment A. Gastric Sleeve is investigational and not coevered. |
N/A |
BCBS Georgia Website
|
| Blue Cross Blue Shield of Illinois |
Per Policy Bulletin SUR716.003, insurance requires five-year history, 6 month diet, psych evaluation, and willingness to comply letter. Sleeve and StomaphyX are investigational and not covered. |
N/A |
BCBS Illinois Website |
| Blue Cross Blue Shield of Massachusetts |
Per Policy Bulletin 379, insurance requires one diet consult with history of previous weight loss attempts. Sleeve is investigational and not covered. |
N/A |
BCBS of Massachusetts Website |
| Blue Cross Blue Shield of Michigan |
Per Policy Bulletin – The Record of March 2005, insurance requires medically supervised 12 month diet failure, PCP clearance and psych evaluation. Sleeve is investigational and not covered. |
N/A |
BCBS of Michigan Website |
| Blue Cross Blue Shield of Minnesota |
Per Policy Bulletin IV-19, insurance requires two year history of morbid obesity, 6 month diet failure, psych evaluation and compliance letter – Blue Cross does not cover commercial weight loss programs - Gastric Sleeve may be considered with BMI >50 and severe co-morbid conditions. |
N/A |
BCBS of Minnesota Website |
| Blue Cross Blue Shield of Mississippi |
Per Employee Access Policy Bulletin, insurance requires five-year history of morbid obesity, documentation of failed diet attempts and TSH. Sleeve is investigational and not covered. |
N/A |
BCBS of Mississippi Website |
| Blue Cross Blue Shield of Nebraska |
Per Policy Bulletin 1.23, insurance requires five-year history, no treatable medical cause for obesity and over age 16. Sleeve is investigational and not covered. |
N/A |
BCBS of Nebraska Website |
| Blue Cross Blue Shield of New Mexico |
Per Policy Bulletin SUR716.003, prior to determining the coverage for surgical treatment of obesity, conservative treatment options must have been tried and have failed. The condition of morbid/clinically severe obesity must be of at least five years duration, Nonsurgical methods of weight reduction must have been unsuccessfully attempted for at least five years under physician supervision. |
N/A |
BCBS of New Mexico Medical Policies PDF |
| Blue Cross Blue Shield of North Carolina |
Per Policy bulletin SUR6710, the patient must have undergone a thorough evaluation, documented to assess his suitability for surgery and their ability to comply with lifelong follow up. 5-year history required, 6 month diet, psych evaluation. |
N/A |
BCBS of North Carolina Obesity Surgery |
| Blue Cross Blue Shield of North Dakota |
Per Corporate Medical Policy, insurance requires physician documentation of weight loss measures over the past 5 years, three-year weight history and psych evaluation. Limited to one procedure per lifetime. Sleeve is investigational and not covered. |
Not Covered |
BCBS of North Dakota Website |
| Blue Cross Blue Shield of Oklahoma |
Per Policy Bulletin SUR716.003, insurance requires five-year history, 6 month diet, psych evaluation and willingness to comply letter. Sleeve is investigational and not covered. |
Not Covered |
BCBS Oklahoma Health Insurance Site |
| Blue Cross Blue Shield of Tennessee |
Per medical policy, insurance requires completion of the Pre-Bariatric Evaluation Tool, requests documentation of specific dates of diets, length of diets with successes and failures for past two years, PCP must document 10% weight loss, five year history and psych evaluation. Gastric Sleeve may be covered on case by case determination. |
Not Covered |
BCBS Tennesse Health Insurance Site |
| Blue Cross Blue Shield of Texas |
Per Policy Bulletin SUR716.003, prior to determining the coverage for surgical treatment of obesity conservative treatment options must have been tried and have failed. The condition of morbid/clinically severe obesity must be of at least five years duration, Nonsurgical methods of weight reduction must have been unsuccessfully attempted for at least five years under physician supervision. |
N/A |
BCBS Texas Medical Surgery Policies |
| Blue Shield of California |
Per Policy Bulletin, insurance requires completion of Prior Auth Review sheet, medical/surgical evaluation and clearance, psych evaluation and one diet consult. |
N/A |
Blue Shield of California Health Insurance Site |
| Champ VA |
Per Policy Bulletin 38 CFR 17.270(a) and 17.272(a)(22) with Related Authority 32 CFR 199.4(e)(15), insurance requires BMI over 40, BMI over 35 with an associated co-morbid or revision due to complications. Sleeve is investigational and not covered. |
Not Covered |
Champ Virginia Health Insurance |
| Cigna |
Pre Authorization Required. Treatment for patients who have been unsuccessful with diet and exercise and have acquired complications. |
Not Covered |
Cigna Bariatric Surgery Coverage PDF |
| Empire Blue Cross |
Per Policy Bulletin SURG.00024, insurance requires diet consult, exercise consult, TSH, psych evaluation and attendance at support groups. Sleeve is investigational and not covered. |
Not Covered |
Empire Blue Cross Health Insurance PDF |
| Excellus Blue Cross |
Per Policy Bulletin 7.01.29, insurance requires 5-year history, 6 month diet, TSH, documented 6 month abstinence from drugs/alcohol and psych evaluation. Sleeve is investigational and not covered. |
Not Covered |
Excellus Blue Cross Medical Coverage page |
| First Health |
Per faxed policy, insurance requires 3 month multi-disciplinary diet approach, psych evaluation, cardiac evaluation, pulmonary evaluation and post-op program. |
N/A |
First Health Bariatric Surgery Plan |
| Great West |
Effective April 1, 2008 Great West is Cigna – see Cigna for requirements. |
N/A |
Cigna Health Coverag |
| Health Scope Benefits |
Per faxed policy, insurance requires initial history and physical exam with office notes and any lab work done |
N/A |
Health Scope Benefits |
| Horizon Blue Cross Blue Shield of New Jersey |
Per Policy Bulletin 022, insurance requires five-year history of morbid obesity, 6 month diet and exercise program and psych evaluation. Sleeve is investigational and not covered. |
Not Covered |
Horizon BCBS New Jersey Members Site |
| Humana |
Per Policy Bulletin, insurance requires 6 month medically supervised diet, Primary Care Physician clearance and psych evaluation. Sleeve is investigational and not covered. |
Not Covered |
Humana Bariatric Management Resources |
| Independence Blue Cross |
Per Policy Bulletin, 11.03.02e insurance requires medical clearance, psych clearance and one time in-depth diet consult. Sleeve is investigational and not covered. |
Not Covered |
IBX bulletin |
| Medicare |
Per Policy Bulletin S-131A, insurance requires BMI of >35 with at least one co-morbid condition, minimum two year history of morbid obesity, 6 month PCP diet or 3 month multi-disciplinary diet, exercise and behavior modification program with neither supervised by the surgeon and psych evaluation. It will not be covered when it is used to treat type 2 diabetes in a beneficiary with a BMI below 35. Sleeve is investigational and not covered. |
Not Covered |
Official Medicare Government Site |
| Pacificare Secure Horizons |
Patient needs to have tried non-surgical treatment approaches including dietary counseling, exercise, behavior modification and support.Gastric surgery should be generally be limited to a) patients with “clinically severe obesity†(BMI ≥ 40) or for those with a BMI of ≥ 35 with significant medical comorbidities. |
Not Covered |
Harvard Pilgrim Bariatric Surgery |
| Premera Blue Cross |
Per Policy Bulletin CP.MP.PR.7.01.516, patient only requires form 14784 faxed in with letter of medical necessity and after care explanation letter. Sleeve is investigational and not covered. |
Not Covered |
Premera Blue Cross Policy |
| Principal Financial Group |
Per fax transmission, insurance requires three-year history, 6 month diet supervised by physician other than surgeon and psych evaluation. |
Not Covered |
Principal Finance Group Corp Website |
| Regence Blue Shield |
Per Policy Bulletin 58, insurance requires documentation of active participation for at least six months in a structured, medically supervised nonsurgical weight reduction program; include at least three visits for medical supervision and psych evaluation. Sleeve is investigational and not covered. |
Not Covered |
Regence Blue Shield Surgery Coverage |
| Unicare |
Per Policy Bulletin SURG.00024, insurance requires completion of Attachment, one in depth diet consult, psych evaluation and compliance letter. Sleeve is investigational and not covered. |
Not Covered |
Unicare Medical Policies |
| United Health Care |
No set policy bulletin. Each case to be evaluated individually. |
N/A |
United Health Care |
| United Health Care THR |
Patient has a $4000 bariatric co-pay and must attend five months of Healthy Weight – NO LAP BAND. |
N/A |
United Health Care |
| Wellmark Blue Cross Blue Shield |
Per Policy Bulletin 07.01.17, insurance requires patient to have Body Mass index (BMI) 40 or above or body-mass index (BMI) > 35 with documented for 3 years or more with at least one obesity related condition, documented failure of medically supervised weight loss for at least 6 months, psychological evaluation. Sleeve is investigational and not covered. |
Not Covered |
Medical Calc System Morbid Obesity PDF |
