Obesity is a widespread health concern in the United States that affects 42% of adults. Bariatric surgery can be life-changing, offering patients the opportunity to significantly improve their health and quality of life. Many insurance companies cover bariatric surgery or weight loss surgery, though coverage varies by policy and the individual. However, securing insurance predetermination is one of the most important steps before a patient can proceed with weight loss surgery. This process helps ensure that the patient’s insurance will cover the costs of the procedure, based on medical necessity and policy guidelines.
Simplify your predetermination and insurance authorization process
From an insurer’s perspective, weight loss surgery is considered medically necessary because it can reduce the health risks associated with severe obesity. Recent studies found that weight loss surgery is associated with increase in life span. A new 40-year study of nearly 22,000 bariatric surgery patients in Utah revealed that weight loss surgery significantly lowers the risk of premature death, particularly from obesity-related conditions like cancer, diabetes, and heart disease.
Understanding how to navigate bariatric insurance predetermination is crucial for both healthcare providers and patients. For healthcare providers, partnering with an insurance authorization company is a practical way to navigate the complex bariatric insurance predetermination process, increasing the chances of getting timely approval for bariatric surgery.
What is Bariatric Insurance Predetermination?
Bariatric insurance predetermination is the process of seeking approval from an insurance company before a bariatric surgery is performed. It involves submitting detailed medical records and other documentation to show that the patient meets the criteria for surgery under their insurance policy.
In addition to basic requirements that are common to all insurers, there are requirements that vary by insurance carrier. If approved, the insurance payment and the patient’s financial responsibility are clarified upfront, reducing the risk of unexpected coverage issues. However, predetermination is not a guarantee of final approval.
Criteria for Bariatric Surgery Approval
Insurance companies often have strict guidelines regarding who qualifies for bariatric surgery. These criteria may vary by insurer, but typically include:
- Body Mass Index (BMI): Most insurance plans require patients to have a BMI of 40+, or a BMI of 35 with obesity-related comorbidities such as diabetes, hypertension, or severe sleep apnea and other potentially life-threatening medical or obesity-related condition.
- Weight: Patients currently weigh at least 100 pounds more than their ideal weight.
In addition to these requirements, insurers may ask for:
- Documentation of previous weight loss attempts: Insurers may ask for documentation of failed attempts at weight loss through diet, exercise, or other non-surgical methods. Most companies require patients to have completed a program lasting at least six months. Acceptable documentation of attempted weight loss typically includes: detailed medical records from a healthcare provider showing consistent weight monitoring, documented participation in structured weight loss programs like Weight Watchers or Jenny Craig, food diaries, exercise logs, and data on nutritional counseling visits. The documentation should demonstrate a sustained effort to lose weight without success.
- Evidence of comorbid conditions: Insurance companies often require evidence of obesity-related health issues to justify the medical necessity of surgery.
- Psychological evaluation: Many insurers require an evaluation to ensure the patient’s readiness for surgery and confirm that they do not have any disorder that may prevent them from being able to maintain the lifestyle changes required post-surgery.
- Medical codes: When submitting a bariatric surgery predetermination request to an insurer, it is important to provide clear and detailed information, including the specific type of surgery being requested and its corresponding medical codes (CPT, ICD-10, or HCPCS). ICD-10 code Z98.84 is used to indicate the status of a patient after bariatric surgery. Below are common types of bariatric surgeries along with their associated CPT codes:
- Gastric Bypass Surgery (Roux-en-Y Gastric Bypass)
- Sleeve Gastrectomy (Vertical Sleeve Gastrectomy)
- Adjustable Gastric Banding (Lap-Band Surgery)
- Duodenal Switch (Biliopancreatic Diversion with Duodenal Switch)
- Intragastric Balloon Placement
- Endoscopic Sleeve Gastroplasty (ESG)
- Biliopancreatic Diversion (BPD)
- Other Bariatric Procedures
CPT Codes: 43644: Laparoscopy, gastric bypass; 43845: Open gastric bypass
CPT Codes: 43775: Laparoscopy, sleeve gastrectomy; 43842: Open sleeve gastrectomy
CPT Codes: 43770: Laparoscopy, gastric restrictive procedure; placement of adjustable gastric band; 43843: Open gastric banding
CPT Codes: 43845: Open duodenal switch; 43644: Laparoscopy, duodenal switch
CPT Codes: 43752: Insertion of intragastric balloon
CPT Code: 43229: Endoscopic sleeve gastroplasty (a newer procedure)
CPT Code: 43843: Open biliopancreatic diversion
CPT Codes may vary depending on the procedure but typically include modifications of the above listed ones.
- Revisional Bariatric Surgery: For patients who have had a prior bariatric surgery and are requesting a revision (such as a conversion from gastric banding to sleeve gastrectomy):
CPT Codes for revision depend on the surgery being performed (e.g., 43644 for gastric bypass, 43775 for sleeve gastrectomy).
In addition to listing the procedure codes, the documentation should include the ICD-10 codes for obesity or other comorbidities that qualify the patient for bariatric surgery (e.g. E66.01: Morbid (severe) obesity due to excess calories; E66.09: Other obesity; E66.2: Morbid obesity with other obesity-related conditions; E11.9: Type 2 diabetes without complications; G47.33: Obstructive sleep apnea, adult type).
Steps in the Bariatric Surgery Predetermination Process
Securing bariatric insurance predetermination involves the following key steps:
- Insurance Eligibility Verification: Confirm the patient’s insurance coverage and eligibility for the proposed bariatric surgery and determine if the insurer mandates predetermination for approval.
- Review Insurance Policies: Understand the patient’s plan requirements, including necessary documentation like medical necessity letters or psychological evaluations.
- Complete Documentation: Compile complete medical records, including BMI, health history, and weight loss attempts.
- Submit Documents: Ensure all forms are completed correctly and records are accurate and submitted promptly.
- Follow Up: Monitor the request’s progress and quickly address any additional insurer requests.
Navigating predetermination for weight loss surgery can be challenging for several reasons. Some insurers may deny coverage based on strict criteria or lack of sufficient medical documentation. Moreover, even when everything is submitted correctly, some insurers may take longer than expected to process the request. Insurance policies and guidelines may change, adding to the complexity of submitting the predetermination request.
For a smooth bariatric insurance predetermination process, providers should focus on the following:
- Clear communication: Both providers and patients should communicate clearly and frequently to ensure that all necessary steps are taken. Providers should explain the process to patients and help them gather the required documentation.
- Prepare for appeals: If the initial predetermination request is denied, be prepared to appeal. Providers should assist patients in providing additional information or re-submitting documentation to meet the insurer’s criteria.
- Stay Organized: Keeping detailed records and following a systematic process helps avoid missed steps or missing information.
- Stay up-to-date with insurance guidelines: Providers should stay updated with any changes to coverage or criteria of insurance policies.
- Know how to handle delays/denials: If the request is taking longer than expected to process the request, providers should stay proactive in following up with the insurer to ensure timely approval. If the insurer denies the predetermination request, providers should assess the reason for the denial and file an appeal if necessary.
Expertise Matters
Proper preparation, clear communication, and thorough documentation are key to the smooth navigation of the bariatric insurance predetermination process. Partnering with a specialist in bariatric surgery insurance verifications and authorizations can go a long way in ensuring smoother precertification request submissions and approvals. Experts have a thorough understanding of the requirements of different insurance companies, and will submit accurate and complete information, increasing the chances of getting timely approval for bariatric surgery to support the patient’s health journey.
Learn about our professional insurance authorization services.
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