Insurance / Costs Denver

How To Meet The Insurance Requirements

The National Institute of Health’s criteria are important to know if you want insurance to cover your weight loss surgery. While insurance companies will take a while to give you the information you need and are likely to give you the run around, here are some helpful steps you can take to help the process along and insure that your surgery is covered.

1. Read and fully understand your insurance company’s certificate of coverage so that you know exactly what should be covered.
2. Document all personal health information, including:
   • Height
   • Weight
   • BMI (body mass index)
   • Diet history
   • Medical problems related to obesity
   • Copy of your primary physician’s medical record to document weight over the last 5 years
3. Document every obesity-related doctor visit you make, including visits to diet centers, fitness clubs, and weight loss programs.
4. Letter of medical necessity from your primary care doctor.
5. Make sure you keep all receipts and accurate records of your expenses relating to doctors visits and weight loss attempts.
6. Call your insurance company to find out if weight loss surgery is covered, which types are approved and if you can choose your own surgeon. (If this is not explained in your certificate of coverage)

Also, know the codes that the insurance companies use for weight loss surgery. The Diagnosis Codes, among others, are:

• Morbid Obesity 278.01
• Diabetes 250
• Hypertension 401
• Sleep Apnea 327.23

The CPT Procedure code for Lap-Band surgery is 43770 and refers to a “gastric restrictive procedure, without gastric bypass, for morbid obesity.” Another code is 43774 , which refers to a “gastric restrictive procedure with gastric bypass and Roux-en-Y.” Use this for a gastric bypass surgery. Another CPT code is 43775; this is used for “longitudinal gastric resection (vertical sleeve gastrectomy).

Ask Your Insurance Company

It is important to keep a detailed record of every time you speak with your insurance company about weight loss surgery. Write down their answers to your questions along with the person’s name and the exact number, including the extension, and date you called. When you speak with a customer service representative from your insurance company, here are some important questions to ask:

1. Is surgery for morbid obesity covered with my current insurance plan?
2. You have been morbidly obese for at least five years prior to surgery.
3. For the past two years, you have attempted other methods of weight loss at the advice of your doctor, such as diets and exercise.
4. You have another pressing medical condition, such as hypertension, diabetes, sleep apnea,degenerative arthritis, and heart disease. These can constitute medical necessity for obesity surgery if your BMI is at least 35.
   Please remember to mention any other major health conditions to your physician and bariatric doctor, including psychiatric or emotional problems. Also mention if you have:
   • Height
   • Weight
   • BMI (body mass index)
   • Diet history
   • Medical problems related to obesity
   • Copy of your primary physician’s medical record to document weight over the last 5 years

Participating Insurance Companies

We accept most major medical plans. Listed below are a few of the insurance companies that Western Surgical Bariatric Center accepts. This, however, is not a guarantee that your insurance will cover your surgery. Thus, it is very important to consult with your insurance provider about all specific requirements.

• Aetna
• Blue Cross Blue Shield
• Cigna
• First Health
• Humana
• Medicare
• United Healthcare

Western Surgical Bariatric Center accepts most medical insurance carriers. Please contact our office for more information.

If your insurance provider indicates that you have an “exclusion” on your policy, this means that your employer does not cover bariatric surgery. Unfortunately, if you have an exclusion, letters or appeals from our office will not change your insurance coverage. Only your employer can make this change by choosing to cover bariatric surgery as a benefit to their employees.

If you have an exclusion, we recommend that you to speak with your human resources director and ask if there may be plans to cover this benefit in the coming year. We have had several patients in our program convince their employers that the benefits of weight loss surgery – including stopping their expensive medications, less time off from work due to related conditions and illnesses, and generally being more productive – outweighed the cost to cover the benefit, and they were successful in gaining coverage.