Bariatric Surgery Insurance FAQs

Quick answers to commonly asked questions about insurance coverage for weight loss programs and bariatric surgery.

Q. How do I know if I am eligible for weight loss surgery?

A. The Weight Loss Center at PinnacleHealth follows guidelines supported by the National Institutes of Health in order to determine a patient's eligibility for weight loss surgery. Rather than using weight, we use body mass index (BMI) as a criteria for surgery -- excess fat in relation to height. Individuals are candidates for surgery if:

• They have failed previous attempts at weight loss in a medically supervised program.
• Their BMI is greater than 40 or between 35 and 40 with major obesity-related medical problems such as diabetes, sleep apnea, hypertension.
• Before becoming eligible for surgery, you will meet with our bariatrician, surgeons, dietitians, psychologists, and members of our nursing staff for a full evaluation.

Q. Will my health plan cover bariatric surgery?

A. Depending upon your type of insurance plan there may be exclusion for weight loss treatments, including surgery. Your insurer may require you to meet certain conditions before having the procedure or to demonstrate that other methods for weight loss have failed. Other plans will have certain requirements before agreeing to pay for the surgery, such as a medically supervised diet history and the need for psychological evaluation. Not all plans have the same requirements. Obtain a printed copy of your insurance company's requirements and document all contacts you have with the insurance company.

Q. What procedure codes and diagnosis codes are used for my services?

• Laparoscopic gastric bypass: 43644
• Laparoscopic sleeve gastrectomy: 43775
• Office visits: 99211 to 99215
• RD visits: 97802 and 97803

Diagnosis codes most commonly used are 278.01 (morbid obesity) and 278.00 (obesity).

Q. Why do I have to wait so long for my surgery?

A. Many steps must be taken between deciding to have the surgery and the actual procedure, including insurance requirements, medical clearances, and insurance authorization. If you are trying to have your insurance pay for the surgery, your first step should be to contact your insurance company for flexible surgery and medical benefits.

Once authorization is obtained you will be contacted to schedule a mandatory pre-operative nutrition and a pre-operative education class that you must attend or your surgery will be canceled until after you attend the classes.

Q. Why do I need a psychiatric evaluation?

A. Our bariatric providers, as well as many insurance companies, require a psychiatric evaluation to ensure your health and safety. Weight loss surgery is a life altering procedure. An evaluation ensures that you:

• Know and understand the risks of the surgery
• Understand the consequences of your decision
• Have no underlying psychological conditions that would prohibit you from adhering to the life changes that are required following surgery.

Q. Why would my insurance company deny coverage for a life-threatening disease?

A. Payment may be denied because there may be a specific exclusion in your policy for obesity surgery or "treatment of obesity."

Insurance payment may also be denied for lack of "medical necessity." A therapy is deemed to be medically necessary when it is needed to treat a serious or life-threatening condition. In the case of morbid obesity, alternative treatments such as dieting, exercise, behavior modification, and some medications may be considered sufficient. Medical necessity denials usually hinge on the insurance company's request for some form of documentation, such as one to five years of physician-supervised dieting or a psychiatric evaluation, illustrating that you have tried unsuccessfully to lose weight by other methods.

Q. Why are weight loss services not covered under my insurance?

A. Weight gain is sometimes the result of a specific medical condition or a side effect to treatment of a medical condition. Weight loss may even be recommended as treatment for a chronic medical condition. Despite these facts, few medical insurance policies will cover services for the sole purpose of weight loss. Your insurance carrier may tell you that they pay for services, labs, or tests included in our weight loss programs. This is true however these services must be associated with a limited set of diagnosis codes. Currently insurance carriers are reluctant to pay for any service associated with the diagnosis of overweight, weight gain or obesity.

You are responsible for verifying that your insurance company pays in a timely manner. Fulfilling this responsibility may require you to contact your insurance company. Your coverage is between you and your insurance company. We will help you present your claim, but you must take ultimate responsibility for your account.

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