Calling Your Health Plan

Your objective is to collect information from your insurer to determine what your plan of action will be.

Before Calling

1. Carefully research and select a number of bariatric surgeons you are interested in.
2. For each surgeon, check our site to see if information is available about what dietician and psychologist that surgeon usually sends his or her patients to.
3. Start a folder to contain paperwork for all your insurance dealings and be ready to take notes from your call for safe keeping here.
   

Your Call

1. When you get through to a service representative at your health plan, record the name of the person you speak with. Record the date and the time of the conversation. Take good notes.
   
   
2. Ask your insurer what policy they have on specific CPT codes. Health plans approve medical procedures based on diagnosis codes. The diagnosis code for morbid obesity is 278.01. Procedures are coded by the medical industry with things called CPT Codes. Bariatric surgery can encompass several CPT codes, depending upon which procedure type is used. Below is a list of CPT codes. For each code, ask what their reimbursement policy is. The usual response for each is 'approved if medically necessary'. See if they tell you that. Another possibility is that they have what is called a 'written exclusion policy'. In either case, carefully record what they say for each code.
   
   

   CPT Codes
   43846	Short limb RNY
   43847	Long limb RNY
   43659	Laparoscopic
   43847	Duodenal Switch
   47600	Duodenal Switch Related
   43633	Duodenal Switch Related
   43659	Adjustable Gastric Banding (Lap Band)

   
   
3. Find out which surgeons your heath plan reimburses for. A simple way to do this is to ask them what surgeon you would need to use to have any of the procedures above performed. It is possible that they may tell you. More likely, you will need to provide them with the names of surgeons you have researched and they will tell you if each surgeon is in or out of network.
   
   
4. Ask about reimbursement amounts & alternatives. Depending upon your plan type, you might be covered for only one surgeon and receive no insurance coverage for anyone else. Alternatively, you might have a small co-payment with one or more surgeons but still have coverage but with a much larger co-payment for any other surgeon. Carefully record your options.
   
   
5. Repeat the above two steps for a) dieticians and b) psychologists. Most health plans will not approve surgery unless a patient has a letter from a dietician and also a psych evaluation from the psychologist (or psychiatrist). They use the latter to help identify individuals at high risk for postoperative failure.
   
   
6. Confirm referral requirements. Are you able to schedule an appointment with a dietician and a psychologist yourself directly? Or, do you need to be referred to them by your primary care physician? Also, ask to confirm whether you need a formal referral from the primary care physician in order to see a specific bariatric surgeon.
   
   
7. Ask about the letter of medical necessity. Health plans rarely authorize coverage for bariatric surgery without something called a letter of medical necessity. This letter explains why surgery is a non-cosmetic, life-saving procedure. It is usually written by the bariatric surgeon. Ask your insurer if it has any policy stating if the letter must come from the surgeon, or if on the other hand it would accept one from the primary care physician as well.
   
   
8. Before hanging up, make sure you've recorded all the information above on paper and asked for clarification on any questions you had.

Does your insurance cover your surgery?  If you are needing additional assistance in finding a surgeon in your area please contact us Monday-Friday 9am-5pm PST 1-866-297-4964.