Bariatric surgery will be available for patients who meet all of the following criteria:
- Employee or covered spouse must be covered under Duke Select, Blue Care or Duke Options
- Employee must be employed at Duke in a benefit-eligible category for at least 2 continuous years as reflected by your most recent current continuous service date on file
- Patient must have a Body Mass Index (BMI) of 40 or more, or between 35-39 BMI with significant co-morbid condition
- Patient must meet the applicable medical/psychological policy criteria
- Complete 3-months of Pathways to Change Health coaching through Duke's employee wellness program (LIVE FOR LIFE) no more than 6 months prior to the date of surgery
- Eligible individuals may receive one procedure per lifetime. If you are in need of a revision of a previous bariatric surgical procedure, your revision will be covered if you meet the required medical policy criteria for the revision.
For members who reside in the state of North Carolina, the surgery will only be available at Duke Regional Hospital. There will be a co-pay of $2,500.
Employees who permanently reside in another state may access a BCBS participating provider for these services, but eligibility requirements, applicable medical policy criteria, and prior review certification must be met.
Ask your physician for more information if you believe you are eligible for bariatric surgery.
Frequently Asked Questions
Which Duke health plans provide coverage for bariatric surgery?
The Duke Select, Blue Care and Duke Options plans all provide bariatric surgery coverage assuming the individual meets all the eligibility criteria. Bariatric surgery is not covered if you have the Duke Basic plan. Members who reside in the state of North Carolina must receive services at the Duke Metabolic and Weight Loss Surgery Center. BCBS members who reside outside the state of North Carolina may access a provider other than a Duke provider for these services.
How many years of service with Duke are required in order to be eligible for the bariatric surgery benefit?
The benefit will be available after the employee has two years of continuous service (as verified by the most recent continuous service date on file) with Duke University or Duke University Health System. The member must meet the 2 year requirement prior to entering the evaluation stage.
What is the coinsurance/copay that I am responsible for?
You are responsible for the $2,500 copay, which must be paid-in-full at the time of the surgical procedure. This copayment applies to the surgery only. In addition, you will be responsible for the applicable deductibles, coinsurance and copayments for other services provided to you including but not limited to office visits, labs or x-rays prior to the surgical procedure.
Prior to my bariatric surgery and after my surgery, what is my responsibility for copays, coinsurance, etc. under my Duke health coverage plan?
There are two components to this benefit once you have met the precertification requirements and are eligible for the benefit.
The first is the "Evaluation" component which is designed to provide education for you and information for the Duke Metabolic and Weight Loss Surgery Center surgeon and will result in a decision by you and your surgeon about the appropriateness of a surgical weight loss procedure for you. You are responsible for copayments associated with the services involved in this Evaluation according to your normal benefits ($20 primary care, $55 specialist).
Subsequently, when it is determined that you are an appropriate candidate for a bariatric surgical procedure and you decide to proceed with obtaining the service, there is a "package" of services included in the definition of "bariatric surgery" which include the surgery itself, and the additional attention of the surgeons during the defined post-operative period. Your responsibility for this benefit is $2,500. The standard benefits as described in the Schedule of Benefits will apply in relation to all other services.
When do I pay the $2,500 copayment?
Payment will be requested once you meet the precertification requirements and your surgery has been approved by your health plan. The $2,500 copayment must be paid in full to the hospital at least two weeks prior to your surgery date or your surgery will be cancelled.
What if I cannot pay the $2,500 in one payment?
Please contact a Financial Care Counselor at the Metabolic Weight Loss Clinic to make other payment arrangements, i.e., installment payments, to pay the $2,500 co-payment prior to surgery.
May I have my surgery performed by the physician of my choice and the facility of my choice?
If you permanently reside in the state of North Carolina, the surgery is covered only if performed at Duke Regional Hospital by a Duke Metabolic and Weight Loss Surgery Center surgeon and you meet the requirements of the Duke Metabolic and Weight Loss Surgery Center. The Duke Metabolic and Weight Loss Surgery Center surgeon must also request precertification from Aetna if you are on the Duke Select plan or BCBSNC if you are on the Duke Options or Blue Care plan. Employees who permanently reside in another state may access a BCBS participating provider for these services, but prior review and certification with BCBSNC must be obtained.
Are my dependents eligible for bariatric surgery assuming I have met my two years of continuous service as an employee with Duke?
Yes, assuming that the dependent is at least 18 years of age and meets all other eligibility requirements.
Does the Duke bariatric surgery benefit allow me to have another bariatric surgery if the first procedure does not work?
The benefit provides for one bariatric surgery procedure per lifetime. It does provide for lap band adjustments, even if the surgery was performed elsewhere. A revision of a previous bariatric surgical procedure will be covered if you meet the required medical criteria for the revision.
If I had bariatric surgery under another policy prior to Duke providing benefits for bariatric surgery, am I permitted to have an additional bariatric surgery as a Duke member providing I meet all the other eligibility requirements?
A revision of a previous bariatric surgical procedure will be covered if you meet the required medical criteria for the revision. Lap band adjustments are also covered.
Will any of my benefit limits such as nutritional visits be reduced by me entering the bariatric surgery program?
In general, any services you have as a component of your evaluation and post-operative visits will not count toward your limits listed in your Schedule of Benefits. However, nutritional visits received at the Duke Metabolic and Weight Loss Surgery Center will count toward your benefit limits. You may see a nutritionist with LIVE FOR LIFE, or participate in their health coaching program at no charge.
How do I enroll in the required 3-month Pathways to Change health coaching program through LIVE FOR LIFE?
To enroll, contact the Pathways to Change coordinator, Sally Neve, RD at 681-0525 or firstname.lastname@example.org.
When should I complete the required 3-month health coaching program in preparation for surgery?
You must complete at least 3-months of the approved health coaching program no more than 6 months prior to the procedure. Most enroll after their initial appointment with the metabolic clinic during the evaluation period, and continue activity in the program during the year following surgery.
What happens if I start a program with LIVE FOR LIFE, but don't indicate that I want the program to count towards the 3-month multidisciplinary program required for the Bariatric Surgery evaluation?
Because LIVE FOR LIFE’s pre-bariatric health coaching program is tailored to those planning an upcoming procedure, you must identify that you wish to enroll in the Pathways to Change health coaching program. Completion of LIVE FOR LIFE’s lifestyle management health coaching program will not meet the surgery requirements. Completion of the program is no guarantee that your surgery will be approved.
Are any complications due to a previous surgery for morbid obesity covered under another carrier's policy or self-pay prior to me becoming a member under Duke's health benefit plan policy covered by my Duke plan?
Complications due to surgery covered under another policy or self-pay will only be covered if due to a medical emergency and then only covered until you are stabilized. A revision of a previous bariatric surgical procedure will be covered if you meet the required medical criteria for the revision.
After I have my surgery, will my health plan cover surgery to remove any excess skin?
If your situation is approved under the medical necessity criteria, it will be covered with a $2,500 co-pay.
If I had lap-band surgery prior to January 1, 2010, will adjustments be covered under this benefit?
The adjustments will be covered only at Duke.
When lap-band adjustments are required, what is my member responsibility for payment?
Your benefits will revert back to your standard benefits in your health plan Schedule of Benefits.
Who do I call if I have a question about my bariatric surgery benefits?
For general health plan inquiries, you may call the health plan customer service number located on your health plan member ID card. For precertification, please call the number listed on your ID card.
Once I enter the pre-evaluation phase, will I automatically be eligible for the bariatric surgery?
No, the decision as to whether you will receive bariatric surgery as a covered benefit under your health plan depends on whether you meet all the pre-evaluation and evaluation requirements; you and your Duke Metabolic and Weight Loss Surgery Center surgeon agree that you should proceed with the surgery; and you are approved for the surgery.
When is my process certified?
Once the health vendor has received the precertification request from the Duke Metabolic and Weight Loss Surgery Center, they will render a decision within 3 business days, provided they have all the necessary information. If approved, The DMWLSC will be notified verbally and you will receive a written confirmation of the approval.
If I am denied, what is my appeal process?
If your request for Bariatric surgery is denied, the health vendor will notify you in writing and provide the reason for the denial. The written notification will include detailed instruction on how to appeal the decision.