Insurance And Financial Options

Insurance Coverage for Bariatric Surgery (Weight Loss Surgery) varies between insurance carriers and among individual plans from within your insurance company. If your plan does provide coverage, you will often 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 your insurance company. Our Program Coordinator and our Insurance Specialist are happy to assist you with any questions you may have regarding your specific situation. They will work closely with you and your insurance company throughout this process.

Important information to note:
• Advanced Weight Loss Solutions is a non-participating provider with all insurance companies.
• 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.

Starting the process
The Internet can help you gather information about weight loss surgery and insurance coverage. We recommend visiting the Obesity Law and Advocacy Site (http://www.obesitylaw.com/) and reading (in the Library section) the article “Maximizing Your Chances of Getting Insurance Approval.” 

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.

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 the adjustable gastric band is a covered benefit, this is not a guarantee of coverage or payment.

1. 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 (http://www.obesitylaw.com/).
If the answer is “yes,” then ask what CPT procedure codes are covered and if this includes adjustable gastric band surgery (CPT 43770).
2. 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?
3. 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.

1. Telephone number and extension called: _________
2. Is surgery for morbid obesity a covered benefit? Yes or No
3. Which CPT codes are covered? 43770 adjustable gastric band? Yes or No
4. Do you have a policy on surgery for morbid obesity that I can obtain?
5. Ask whether you are required to see an in-plan provider for the adjustable gastric band surgery. If your insurance plan requires an in-plan provider, and you want to use an out-of-network provider for your surgery, you may need to consult an attorney.

Submission Requirements
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:
1. 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)
2. List of medical problems associated with obesity, such as type 2 diabetes, sleep apnea, hypertension, etc.
3. Number of years patient has been overweight (which should be at least five or more)
4. Number and types of failed weight-loss programs attempted in the past

If you create a document or packet listing all your weight-loss attempts (self-controlled or medically supervised) and their results, you can substantially increase your chances of getting insurance coverage for the adjustable gastric band procedure. You should include any commercial diets or medical records of your weight-loss efforts.

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.

You can also contact a lawyer with expertise to help you with the appeal. More information about legal help can be found at The Obesity Law and Advocacy Web site at http://www.obesitylaw.com/.

Insurance Company Links
Below is the list of companies that are known to either partially or completely cover adjustable gastric band surgery in Virginia, Maryland, Washington D.C. area. If your insurance company is not listed below, it does not mean that the procedure is not covered by your insurance company. Please note that this list in no way insures that your procedure will be covered—it is provided for informational purposes only. Several insurance companies make decisions regarding coverage on a case by case basis.

• Aetna
• Blue Cross/Blue Shield (Anthem)
• Care First
• Cigna
• GEHA
• Great West
• MAMSI
• Medicare
• Mutual of Omaha
• NALS
• Tricare
• United Healthcare

Other Topics

• Seminar Schedule
• Questions For My Primary Care Doctor
• Affordability
• Questions For My Surgeon
• New Patient Forms
• Seminar Schedule
• View Online Seminar