Why Anthem BCBS Denies Bariatric Surgery
BMI does not meet threshold
Supervised weight loss program not completed
Psychological evaluation not documented
Comorbidities not adequately documented
Know Anthem / Blue Cross Blue Shield's Criteria
Anthem uses their own Clinical UM Guidelines and AIM Specialty Health for imaging. Medical policy numbers are publicly searchable.
Key policies to know:
- AIM Specialty Health manages imaging prior auth
- Clinical UM Guidelines searchable at anthem.com/provider
- Known for strict imaging prior auth requirements
- Uses evidence-based medicine approach with published policies
Anthem BCBS's Specific Approach to Bariatric Surgery
Applicable Policy
Anthem Surgery Policy SURG.00032 (Bariatric Surgery)
How Anthem BCBS Typically Denies This
Anthem's criteria vary by state plan but generally require BMI documentation over 2+ years showing sustained obesity. Some Anthem plans require 6 months rather than 3 months supervised weight loss.
Your Strategy for This Payer
Check the specific state plan requirement for supervised weight loss duration -- it varies. Anthem also wants to see that comorbidities are actively managed and documented. Lead with the BMI history and comorbidity documentation.
Key Phrase to Use on the Call
"The patient's BMI has been documented at [X] over the past [Y] years with persistent comorbidities including [list] despite medical management, meeting SURG.00032 criteria for bariatric surgery."
Building Your Medical Necessity Argument
Document BMI >= 40 or BMI >= 35 with comorbidities
Show completion of 3-6 month supervised weight loss program
Include psychological clearance and nutritional evaluation
List comorbidities with supporting clinical data (A1c, BP, sleep study)
P2P Call Tips for Anthem BCBS
Reference specific Anthem Clinical UM Guideline by policy number
For imaging, address AIM criteria specifically
Anthem medical directors appreciate evidence-based arguments
Cite specific clinical criteria being met from their own policy
Guidelines to Reference
- ASMBS/IFSO Guidelines for Bariatric Surgery
- NIH Consensus Statement on Bariatric Surgery
Relevant CPT Codes
Specialty: General Surgery
Want the full strategy?
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