.: Insurance Information :.

Insurance Information

Although weight loss surgery is endorsed by the National Institutes 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."
(If your insurance company does not cover LAP-BAND surgery, financing may still be available. To learn more about financing options please click here>>:

Start by Educating Yourself

The Internet can help you gather information about weight loss surgery and insurance coverage. We recommend visiting the Obesity Law and Advocacy Site (obesitylaw.com) and reading (in the Library section) the article "Maximizing Your Chances of Getting Insurance Approval."
Start by asking patients who have had the surgery about their experience with 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 (see Making Appointments, below.)

Know the codes for weight loss surgery:

The ICD-9 Diagnostic Code for Morbid Obesity is 278.01
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.

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 San Antonio Weight Loss Center.

Step 1: 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. We recommend you contact the Obesity Law and Advocacy Center (obesitylaw.com).
If the answer is "yes," then ask what CPT procedure codes are covered and if this includes LAP-BAND or Gastric Bypass surgery (CPT 43770).
Finally, ask them to send you a copy of their policy 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 No
Which CPT codes are covered?
CPT 43770 LAP-BAND | ICD- 9 code 278.01 Yes No
Do you have a policy on surgery for morbid obesity that I can obtain?
What information do you require before authorizing the surgery?

a.	Nutrition consult required?	Yes	No
b.	Psychological consult required?	Yes	No
c.	Medical clearance from your physician	Yes	No
d.	Note from Surgeon	Yes	No
e.	Documentation of weight loss attempts	Yes	No
f.	Documentation of length of obesity	Yes	No

Ask whether you are required to see an in-plan provider for the LAP-BAND surgery or if you can be treated by a contracted provider such as Jorge L. Rincon, MD FACS at San Antonio Weight Loss Center. If your insurance plan requires an in-plan provider, and you want to use a contracted provider for your surgery, you may need to consult an attorney.
Get the full name and direct telephone extension of the person with whom you spoke.

Step 2. Begin making appointments

Medical History Form: Please fill out our medical history form
(click here >>) and bring it with you to your first appointment.

Date and time of appointment: __________________

Nutrition Consult: Most insurance companies require a consultation with a dietician or nutritional specialist before they will authorize your surgery. Typically, our nutritionist will see you when you come to the office. Just call to schedule. This has a fee of $100 and is not covered by insurance companies. (It is also important to document your past weight loss efforts in as detailed a way as possible. Certificates or receipts for weight loss programs, especially if they were medically supervised and included weight measurements, are very helpful.)

Date and time of appointment: __________________

Psychological Consult: Most insurance companies require a preoperative psychological consultation. You may see our psychologist at your appointment with us for your psychological clearance, or this can be arranged at your first office appointment. This has a fee of $150.00 and is not covered by insurance companies. You may see your own therapist, or we can recommend one. We can provide an information sheet outlining what is required from the psychological evaluation if you choose to use your own psychologist.

Date and time of appointment: __________________

Letter of Medical Clearance and Medical Necessity from your Primary Care Physician (If you are seeking insurance coverage): The most efficient approach is to tell your doctor you want to undergo weight loss surgery and need a complete history and physical prior to the surgery. Ask your doctor to write a description of your weight-related medical problems and to indicate that he or she feels the surgery is medically necessary. Bring the medical history form and information sheet from your primary care provider with you, as this will help your doctor. Request a copy of chart notes documenting your weight at least once a year over the last 5 years, and your weight loss attempts, including medications tried and referrals to a nutritionist and/or behavioral/psychological therapist. If your doctor needs more information on what surgical weight reduction is, or why we are recommending it for you, let them know that they can review the information on our website. If you do not have a primary care provider, we can recommend one for you.

Date and time of appointment: __________________

Please ask the providers you meet with to give you copies of reports and your records. Mail those records to our office. It is also a good idea to obtain printed copies of the reports for your own records.

Call your insurance company to verify that Gastric Bypass and/or Lap Band® are a covered benefit and what and which are the requirements to authorize such weight loss surgery.
The CPT code for gastric bypass surgery is 43846, the CPT code for Lap-Band® surgery is 43770
The diagnostic code (ICD-9) for morbid obesity is 278.01.
Call the member services number on your insurance card. Make sure you talk to a live person and not a recording

These are a list of some insurance companies and examples of some of the requirements that are mandatory prior to consider coverage for weight loss surgery.
These are a guidelines and examples from our experience, they are not the insurance company policies, and you must call your insurance company and ask for your policy requirements, referrals, pre-authorization, deductibles, in-network and out of network benefits.
If you do not find your insurance company on the following list, check with your member services department or your insurance company to find out what your insurance policy requirements are; and you must call your insurance company.

United Healthcare

1. History Physical including Height, weight with co-morbidities
2. Documented 5 years History of Morbid Obesity
3. Documented failure of 6 months of medically supervised non-surgical methods of
    Weight reduction by MD, DO, Nurse Practitioner which includes
      •Nutrition therapy,
      •Behavior modifying exercise or increase activity,
      •Medication therapy and/or maintenance therapy.
4. Psychological Evaluation
5. Documentation of willingness to comply with pre operative and post operative treatment plans.
6. Letter of Medical Necessity to include documentation of morbid obesity for at least 5 years or more,     BMI over 40, presence of co-morbidities, 5 years or more of continuous documented morbid obesity
7. Documented continuous six (6) months of medically supervised weight loss program in the last two     years
8. Cardiac and pulmonary function tests
9. Nutritionist evaluation
10. TSH, current
11. Drug/alcohol screening at their MD (depends on policy)
12. Understands surgical procedure

Blue Cross/Blue Shield

1. History Physical including Height, weight with co-morbidities
2. Documented 5 years History of Morbid Obesity
3. Documented failure of 1 year of medically supervised non-surgical methods of
    Weight reduction by MD, DO, Nurse Practitioner which includes
    • Nutrition therapy,
    • Behavior modifying exercise or increase activity,
    • Medication therapy and/or maintenance therapy.
4. Psychological Evaluation
5. Documentation of willingness to comply with pre operative and post operative treatment plans.
6. Letter of Medical Necessity to include documentation of morbid obesity for at least 5 years or more,     BMI over 40, presence of co-morbidities, 5 years or more of continuous documented morbid obesity

Cigna

1. History Physical including Height, weight with co-morbidities
2. Documented 5 years History of Morbid Obesity
3. Documented failure of 6 months of medically supervised non-surgical methods of
    Weight reduction by MD, DO, Nurse Practitioner which includes
     • Nutrition therapy,
     • Behavior modifying exercise or increase activity,
     • Medication therapy and/or maintenance therapy.
4. Psychological Evaluation
5. Documentation of willingness to comply with pre operative and post operative treatment plans.
6. Letter of Medical Necessity to include documentation of morbid obesity for at least 5 years or more,     BMI over 40, presence of co-morbidities, 5 years or more of continuous documented morbid obesity
7. At least two (2) documented medically supervised diets in the last two years lasting at least 6 months     each (supervised by a physician and a registered dietitian)
8. Nutritionist evaluation
9. Medical clearance from a primary care physician
10. Detailed weight loss history with dates and outcomes for at least 5 years

Aetna

Presence of severe obesity that has persisted for at least 5 years, defined as any of the following:

Body mass index (BMI) exceeding 40 or
BMI greater than 35 with one of the following co-morbidities:

Coronary heart disease
Type 2 diabetes mellitus
Clinically significant obstructive sleep apnea
Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management.

Patient is 18 years of age or older
History Physical including Height, weight with co-morbidities
Documented 5 years History of Morbid Obesity
Documented failure of 6 months of medically supervised non-surgical methods of
Weight reduction by MD, DO, Nurse Practitioner which includes
  • Nutrition therapy,
  • Behavior modifying exercise or increase activity,
  • Medication therapy and/or maintenance therapy.
Psychological Evaluation
Documentation of willingness to comply with pre operative and post operative treatment plans.
Letter of Medical Necessity to include documentation of morbid obesity for at least 5 years or more, BMI over 40, presence of co-morbidities, 5 years or more of continuous documented morbid obesity
Patient must have done one of the following two programs:

Physician supervised nutrition and exercise program that includes a dietitian consultation, low calorie diet, increased physical activity and behavioral modification for the duration of at least 6 months within 2 years prior of surgery. Must be documented in the medical record by an attending physician who supervised the patient’s participation. Documentation should include medical records of MD’s monthly assessment of the patient’s progress throughout the course of the nutrition and exercise program.
Multidisciplinary surgical preparatory program. Must last at least 3 months and include the following:

Consultation with a registered dietitian
Reduced-calorie diet supervised by the dietitian
Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional
Behavior modification supervised by a qualified professional
Documentation in the medical record of the patient’s participation. Documentation should include medical records of the MD’s initial assessment of the patient and the MD’s assessment of the patient’s progress at the completion of the program.

Humana

1. History Physical including Height, weight with co-morbidities.
2. Documented 5 years History of Morbid Obesity
3. Documented failure of 6 months of medically supervised non-surgical methods of
     Weight reduction by MD, DO, Nurse Practitioner which includes
      •Nutrition therapy,
      •Behavior modifying exercise or increase activity,
      •Medication therapy and/or maintenance therapy.
4. Psychological Evaluation
5. Documentation of willingness to comply with pre operative and post operative treatment plans.
6. Letter of Medical Necessity to include documentation of morbid obesity for at least 5 years or more,     BMI over 40, presence of co-morbidities, 5 years or more of continuous documented morbid obesity

Step 3: What we will do

After your first office appointment with us, we send a letter of medical necessity to your insurance company requesting authorization for surgery. You will be asked to sign an "Advanced Beneficiary Notice" stating that you agree to pay the Program Fee one week in advance of the date of your surgery (unless your insurance company is covering your surgery).

How to get started:
1. Download and print patient forms.
2. Make an appointment to see us.
3. Thats it!

Download a PDF Patient Handbook

Download a Medical History Form