Plastic Surgeons in Beverly Hills - Los Angeles - Plastic Surgery

All About Insurance Coverage

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 Beverly Hills Physicians.

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.

1. Telephone number and extension called: _____________________
2. Is surgery for morbid obesity a covered benefit? Yes No
3. Which CPT codes are covered?   CPT 43770 LAP-BAND | ICD- 9 code 278.01   Yes   No
4. Do you have a policy on surgery for morbid obesity that I can obtain?
5. What information do you require before authorizing the surgery?
1. Nutrition consult required?   Yes   No
2. Psychological consult required?   Yes   No
3. Medical clearance from your physician?   Yes   No
4. Note from Surgeon?   Yes   No
5. Documentation of weight loss attempts?   Yes   No
6. Documentation of length of obesity?   Yes   No
6. Ask whether you are required to see an in-plan provider for the LAP-BAND surgery or if you can be treated by a non-contracted provider.
7. Get the full name and direct telephone extension of the person with whom you spoke.

Step 2. Required Appointments

Medical History Form: You will receive a Medical History form in your initial consultation.

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. You can make an appointment with our in-house Nutritionist. (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. We can help you to arrange for this appointment to get your psychological clearance. 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.

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

Check the coverage requirements for some of the larger insurance carriers.