A step-by-step guide to your insurance company:

While below is a step by step guide for many who like it, we can make it simple: 

Call us

Make an Appointment

We will deal with your insurance company

Thats It!

Note: Gastric Plication is not covered by insurance companies. Lap-Band is covered by many insurance companies.

We are pleased that you have chosen us for your weight loss surgery. We are committed to providing a comprehensive weight loss surgery program involving excellent surgery as well as pre and postoperative education, evaluation, and support. We strongly believe that the best results are achieved with a comprehensive program. However, we realize that high quality weight loss surgery is expensive.  This is why we have worked with the hospitals and our anesthesiologists to have the lowest prices for the LAP-BAND and gastric plication in Arizona. In addition, our office works hard to have your band covered by your insurance, if possible. Therefore, we will work with you to help you find a way to pay for the surgery. This may involve paying for the operation yourself, financing the cost through a finance company, or obtaining health insurance coverage for the surgery.

Though insurance coverage of the surgery is often the least expensive option for you, obtaining insurance authorization for weight loss surgery can be frustrating and time consuming. Despite the fact that weight loss surgery is endorsed by the National Institutes of Health as the only effective treatment for morbid obesity, some insurance policies do not cover it at all. Obtaining insurance authorization usually involves the following steps:

Below we will give you a step by step approach for your insurance company. But you can always make your first step an appointment with us. With a consultation we will evaluate whether you would qualify for weight loss surgery, and then you will meet with our coordinator and finance officer.

Steps you can take on your own -:

FIRST KNOW - you don't have to do this. You can, but we will do all of this for you, or help you with this- that is our job and we are very good at our job.

1. Determine if weight loss surgery is a covered benefit in your policy.
2. Determine what the criteria for coverage are (such as weight, BMI, previous weight loss attempts, etc.).
3. Obtain documentation (prior chart notes from your medical doctor are especially good) that you meet all the criteria for coverage required by your insurance policy.
4. Determine which weight loss procedure(s) your policy covers.
5. We will then prepare a comprehensive letter of medical necessity outlining your situation and send it to your insurance company requesting approval for your weight loss surgery.

You need to take an active role in gathering this information. We have outlined the process in detail below to make it as simple and efficient as possible. We recommend that you document every step of the way.

Educate Yourself, Inform yourself: The internet is a useful place to gather information about weight loss surgery and insurance coverage. You should review obesitylaw.com. Go to the Articles Section and review "so you want to get your insurance company to cover surgery?" Walter Lindstrom has a "top ten" list of what to do. Inform yourself about both the insurance issues and the surgical issues. 

Personal information: You should know your height, weight, BMI, diet history and medical problems related to obesity. Some primary care physicians will write a supportive letter detailing the medical necessity for you. There are BMI calculators on many websites. Bring your insurance card with you to your appointment. We recommend 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.

Understand the codes for weight loss surgery:

The ICD-9 Diagnostic Code for Morbid Obesity is 278.01

The CPT Procedure Code is: 43770

 

INSURANCE AUTHORIZATION
We will contact your insurance company to find out if weight loss surgery is a covered benefit, which procedures they will approve, and which hospital or out patient facilities can be used.

 

If you wish to take an active role, please use the checklist below to help you, and be sure to document below every number you call, every individual you speak with, and the time and date that you spoke with them. Bring this with you to your office appointment.

Step 1: Call your insurance company
Call the benefits coordinator at your human resource office and/or call the customer service line 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 they say no, you may need an attorney to help you prove that it is medically necessary. We recommend you contact Walter Lindstrom at Obesitylaw.com. If they say yes, then ask them what CPT procedure codes they cover. The Lap-Band procedure code that you would be inquiring about is CPT 43770. Don't forget to document this. Finally, ask them to send you a copy of their policy on the surgical treatment of morbid obesity (ICD 9 code 278.01). Please note that we cannot call your insurance company on your behalf unless you are our patient. If you wish us to assist you with this, you must be our patient first.

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? 43770 LAP-BAND 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?
 a. Nutrition consult required? Yes No
 b. Psychological consult required? Yes No
 c. Medical clearance from your physician Yes No
 d. Note from Surgeon Yes No
 e. Documentation of weight loss attempts Yes No
 f. Documentation of length of obesity Yes No

6. Ask whether you are required to see an in-plan provider or a contracted provider.  This may make it more difficult for you be approved to see us, and you may need to consult an attorney. This is the most difficult problem for patients in HMOs.

7. Get the full name and direct extension of the person with whom you spoke.

Step 2. Begin making appointments
Once you contact us for an appointment, we will send you-- via email - a

 

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. Typically, our nutritionist will see you first when you come to the office. Just call to schedule. It is 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. This includes chart notes from your Primary Care Physician's office.
Date and time of appointment: __________________

Psychological Consult: Most insurance companies require a preoperative psychological consultation. Many patients already have a therapist or know of one. To expedite the scheduling of your surgery, you may see a psychologist or psychiatrist prior to your appointment with us for your psychological clearance or this can be arranged at your first office appointment. You may see your own therapist, or we can recommend several whom we work with. We can provide an information sheet outlining what is required from the psychological evaluation if you 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 go to your doctor and tell them that you want to undergo weight loss surgery. Tell them that you need a complete history and physical prior to the surgery. Ask your doctor if they would be kind enough to detail your weight-related medical problems and to indicate that they feel the surgery is medically necessary. Bring your questionnaire and information sheet for your primary care provider (supplied by our office) 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 call us or 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: __________________

Be sure to ask all of the individuals you see to fax copies of the reports to our office at (602) 230-8344. It is also a good idea to obtain printed copies for your records.

Step 3: What we will do after your appointment with us

We send a letter of medical necessity to your insurance company requesting authorization for surgery. You will also be asked to sign an "Advanced Beneficiary Notice" . This document will state that you agree to pay the for the surgery one week in advance of the date of surgery unless your insurance company is covering your surgery. Our insurance specialist will send out the request for authorization for surgery within two days of your office appointment. She will verify that you understand the payment policy and answer any questions you may have regarding insurance issues. In some cases, your insurance company will cover the surgery, but they will not contract with us. In this case, we want to maximize the insurance reimbursement for your surgery and refund it back to you as soon as possible. We will always try to advise you of what your chances are of being approved. We will also try to advise you on what to expect in terms of the timing and amount of reimbursement from the insurance company. If weight loss surgery is not covered by your insurance we will help you arrange financing if you are interested.

Your chance of being approved for weight loss surgery by your insurance company will be greatly improved if you gather the information above, and we submit a complete package of information covering all the insurance policy requirements together with our letter of medical necessity.

For further information on costs and other inquiries regarding our financial policy, please feel free to contact our office at (602) 234-8995 and ask for extension 106 to speak with our reimbursement specialist.

Disclaimer: If your BMI is in the range of 20 through 24 you are in the normal weight range. A BMI of 24 through 30 is in the overweight range. A BMI of 30, or greater, may mean your best weight loss option is the LAP-BAND, the safest weight loss surgery.

Because the adjustable laparoscopic band is much safer than gastric bypass operations, patients whose BMI is 30 or greater may be eligible for weight loss surgery.

We encourage you to check out our publications, and learn about losing weight in a safe healthy manner.

There are some things we know about insurance companies:

United Health Care: Easy authorization but a number of their policies have specific exclusions to weight loss surgery.

Blue Cross of Arizona -- currently does  cover the band. Dr. Simpson has worked hard with Arizona Blue Cross to cover the band, and they listened to him. Further, the many requirements that Blue Cross use to have, has changed.  BC of California does, as does Texas and Florida, and some others. Check to see which Blue Cross plan you have, and call that number to see if the band is covered. There is no universal plan for Blue Cross, some require a pre-operative diet, some do not.

Cigna -- improved coverage for the LapBand however, we are considering dropping this company although those who have PPO with out of network benefits can see us

AHHHCS - a number of plans cover the band, but will require some work with your primary care physician.

PHP - Phoenix Health Plan - we have terminated with this plan. They do not have any active weight loss surgeons who do Lap-Band. We suggest that if you are a member of this plan that you switch to APIPA

MercyCare - probably one of the most difficult plans to deal with. They have a six month supervised diet (which we will do with you, and help you learn how to eat with the band before you get it). They also require you use their psychological services, Magellan, for an evaluation and treatment. They will require an exercise plan (which we will help you do, and document). If you gain weight during the six month process they have denied.

Aetna - covers the band and has worked well with surgeons and policy holders.
No staples means the operation is safer - meaning that BMI requirements are lower for the LAP-BAND than the RNY gastric bypass and the gastric sleeve.