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HORIZON BLUE CROSS BLUE SHIELD NEW JERSEY PRE-APPROVAL REQUIREMENTS
Weight loss surgery for treating morbid obesity is considered medically necessary if the patient fulfills the following criteria:
The patient should be at least 18 years of age AND/OR the patient’s skeletal growth is complete.
Weight loss surgery for patients under 17 years of age is not considered medically necessary unless full skeletal growth has been reached and the patient suffers from a co-morbid condition, such as sleep apnea or hypertension.
The patient is morbidly obese (i.e. has a BMI of over 40 OR has a BMI of over 35) with a life-threatening co-morbid disease such as:
Congestive Heart Failure
Metabolic Syndrome
Coronary Artery Disease
Hypertension
Cardiomyopathy caused by obesity
The patient, in the 12 months prior to the surgery, has to have:
Completed a weight loss program for at least six consecutive months
Participated in a surgery preparation program to enhance results and lower risk of complications after the procedure. Your surgeon will typically have these available.
Undergone pre-operative psychological evaluation and understands the impacts of weight loss surgery
The patient should have a letter of recommendation from his/her primary doctor.
The bariatric surgeon should submit the proper paperwork for approval.
The patient has to fulfill all of the criteria listed above to be approved for bariatric surgery.
TYPES OF WEIGHT LOSS SURGERIES COVERED BY HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY
Horizon Blue Cross Blue Shield New Jersey covers the following weight loss surgeries:
Biliopancreatic Diversion with Duodenal Switch
Laparoscopic Adjustable Gastric Banding
Gastric Bypass with Short-Limb Roux en Y anastamosis
Gastric Bypass with Long-Limb Roux en Y anastamosis
Vertical Banded Gastroplasty
Sleeve Gastrectomy
These procedures are considered medically necessary for treating morbid obesity.
PROCEDURES EXCLUDED FROM COVERAGE
Mini-gastric bypass, gastric plication and other surgeries not listed above are considered experimental and not covered.

I have just started my journey for weight loss. I have BCBS of NJ. Just wondering if anyone has any experience in what they require. I have my 1st meeting with Nutrition/Dietician in 2 weeks.

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