There’s only one way to find out if your weight loss or bariatric surgery at our Phoenix area and Tucson offices is covered for sure and that is to review your health plan policy. Upon review, it is recommended to confirm with your health insurance company to see if weight loss surgeries such as gastric bypass surgery, gastric sleeve or the LAP-BAND® procedure are covered.
Some permanent weight loss procedures which reduce health risks can be made more apparent by your surgeon so that your insurer can consider it covered.
Although weight loss surgery is endorsed by the National Institute of Health as the only effective treatment for morbid obesity, not all insurance policies cover the cost of weight loss surgery. Those that do will often require that you provide extensive documentation about your health, along with a letter from one of our physicians stating that your surgery is a “medical necessity.”
Start By Educating Yourself
The Internet can help you gather information about weight loss surgery and insurance coverage. We recommend reading (in the Library section) the article “Maximizing Your Chances of Getting Insurance Approval.”
Attend at least one support group meeting to ask patients who have had the surgery about insurance coverage.
Gather your personal health information, including height, weight, BMI, diet history and medical problems related to obesity. You will also be obtaining a copy of your medical record from your primary care physician to help document your weight over the last 5 years and your prior weight loss attempts, and asking your doctor to write a letter stating the need for weight loss surgery.
Know the Codes for Weight Loss Surgery
The ICD-10 Diagnostic Code for Morbid Obesity is: E66.01
The CPT Procedure Code for LAP-BAND® surgery 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 LAP-BAND® surgery.
The CPT code for Gastric Sleeve is: 43775.
The CPT code for Gastric Bypass is: 43644.
Getting Insurance Authorization
We recommend that you contact your insurance company to find out if weight loss surgery is a covered benefit, which procedures they will approve, and if you are allowed to select the surgeon you prefer. Use the checklist below to document the numbers you call, the people you speak with, and the time and date you speak with them. Bring the completed checklist this with you to your office appointment at the Weight Loss Institute of Arizona.
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. 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 “no,” you may need an attorney to help you prove that it is medically necessary.
If the answer is “yes,” then ask what CPT procedure codes are covered and if this includes LAP-BAND® surgery (CPT 43770), Gastric Sleeve (CPT 43775), Gastric Bypass (CPT 43644).
Finally, ask them to send you a copy of their policy on the surgical treatment of morbid obesity (ICD 10 code E 66.01).
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?
Which CPT codes are covered?
Do you have a policy on surgery for morbid obesity that I can obtain?
What information do you require before authorizing the surgery?
Nutrition consult required?
Psychological consult required?
Medical clearance from your physician?
Note from the surgeon?
Documentation of weight loss attempts?
Documentation of length of obesity?
Get the full name and direct telephone extension of the person with whom you spoke.