Insurance Coverage for Bariatric Surgery varies between insurance carriers and among individual plans from within your insurance company. If your policy provides for bariatric surgery coverage, you may be required to provide documentation about your health history along with a letter from us indicating that the procedure is medically necessary. In addition, many insurance companies also have specific requirements (such as physician supervised weight loss attempts or psychological screening) that must be met prior to giving authorization for surgery.
Please read the following information to get started with the insurance process. Our Insurance Specialist is happy to assist you with any questions you may have regarding your specific situation and will work closely with you and your insurance company throughout the process.
Important information to note:
- Advanced Weight Loss Surgery is a non-participating provider with all insurance companies, except Medicare, Tricare and Adventist Health
- The ICD-9 Diagnostic Code for Morbid Obesity is 278.01
- The CPT Procedure Code for adjustable gastric band is 43770. It refers to a “gastric restrictive procedure, without gastric bypass, for morbid obesity.” The procedure “unlisted laparoscopy procedure, stomach” is also used to refer to adjustable gastric band surgery.
- The CPT Procedure Code for Sleeve Gastrectomy is 43775
- The CPT Procedure Code for Gastric Bypass is 43644
Starting the process
We request you aid us in gathering your personal health information, including height, weight, diet history and medical problems related to obesity. It may be necessary for you to obtain a copy of your medical records from your Primary Care Physician to help document your weight history over the past 5 years and your prior weight loss attempts. Your personal physician may also need to write a letter of medical necessity for the proposed surgery.
Getting Insurance Authorization
We recommend that you contact your insurance company to find out if weight loss surgery is a covered benefit.
Ask which procedures they will approve/cover, and if your plan allows you to use out-of-network providers.
Calling your insurance company
Call the benefits coordinator at your human resource office and/or call the customer service line listed on your insurance card. Once you are connected to a representative, ask the following questions to determine your policy benefits. Please note that even if the representative states that bariatric surgery is a covered benefit, this is not a guarantee of coverage or payment.
- State, “I am inquiring about my policy benefits regarding the surgical treatment of morbid obesity. Is surgery for morbid obesity a covered benefit?”
If the answer is “yes,” then ask what CPT procedure codes are covered and if this includes the procedure you are seeking. The provider that I have chosen is a non-participating provider with all insurance companies. Am I able to use non-participating/out-of-network providers?
- Ask them to send you a copy of their policy (or direct you to a webpage) on the surgical treatment of morbid obesity (ICD-9 code 278.01).
You may use the list below to help you ask all the questions and to document the answers received.
- Telephone number and extension called: _________
- Is surgery for morbid obesity a covered benefit? Yes or No
- Which CPT codes are covered? 43770, 43775, 43644. Yes or No
- Do you have a policy on surgery for morbid obesity that I can obtain?
- Ask whether you are required to see an in-plan provider for the bariatric surgery.
After your initial consultation with the surgeon, we will prepare a “Letter of Medical Necessity” to submit to your insurance company. This letter and a weight-loss history are necessary to obtain prior authorization for obesity surgery. A Letter of Medical Necessity states why significant weight loss is medically necessary for a patient and usually includes the following information:
- The patient’s weight (which should be 100 pounds or more above ideal weight or a BMI more than 40 or at least 35 with associated medical problems to qualify)
- A list of medical problems associated with obesity, such as type 2 diabetes, sleep apnea, hypertension, etc.
- The number of years the patient has been overweight (which should be at least five or more)
- The number and types of failed weight-loss programs attempted in the past
Insurance companies give close consideration to a patient who creates a detailed document or packet listing their weight-loss attempts (self-monitored or medically supervised) and the results of those attempts in their plea for insurance coverage for bariatric surgery.
Insurance Appeals Process
If coverage has been denied upon the initial prior authorization request, you can appeal by addressing the specific reasons why your request has been denied. Our insurance specialist will be happy to help you with your appeal, should one be necessary. You may also view a sample appeals letter by clicking here.
Insurance Company Links
Below is the list of insurance companies that are known to either partially or completely cover weight loss surgery in Virginia, Maryland, and the Washington D.C. area. If your insurance company is not listed below, it does not mean the procedure is not covered by your insurance company.
- Blue Cross/Blue Shield (Anthem)
- Care First
- Great West
- Mutual of Omaha
- United Healthcare