If you meet the basic criteria for Roux-en-Y gastric bypass surgery and are ready to commit to a change in your lifestyle, here is what you need to do next:
Step One: Determine if your insurance company will cover any or all of the costs associated with the surgery.
Since health insurance coverage varies with each person and employer, you need to check your policy to see if it specifically excludes weight loss (or bariatric) surgery. If you are unable to find the answer by reading the policy, call your insurance company.
Specifically, ask if company if the procedure code “CPT code 43846” (open Roux-en-Y gastric bypass) and “CPT code 43659” (laparoscopic Roux-en-Y gastric bypass) is a covered benefit. You need to ask your insurance company what is required in order to provide you with written authorization for the surgery.
Many insurance companies require documentation of medical conditions and medical treatment by your primary care doctor in order to establish whether you meet their criteria. Your primary care doctor needs to generate the authorization. Most insurance companies also require you have one or more of the following prior to approving coverage:
Psychiatric evaluation
Sleep Apnea study
Cardiac evaluation
Primary care physician’s documentation regarding co-morbidities (obesity-related conditions such as diabetes, high blood pressure, high cholesterol, GE reflux, arthritis or sleep apnea)
Primary care physician’s documentation regarding failed supervised diet and exercise attempts as well as gym memberships, Weight Watchers® receipts, and grocery receipts
If your insurance provider does not cover the surgery, ask if this is based on a “written exclusion” in the policy. If there is such an exclusion, there is little you can do other than change providers.
If there is not a written exclusion, you should ask why Roux-en-Y gastric bypass surgery is not covered. Unfortunately, there are some insurance companies that will automatically deny coverage, so be persistent.
Step Two:
Once you have determined your insurance provider’s criteria and conditions or have decided to pay cash, your next step will be to Make An Appointment. Click on The Make An Appointment link above.
Our Bariatric Surgery Clinic Coordinator, who is a registered nurse, will call you back within five to seven business days to see if you meet basic surgery criteria. If so, you’ll be scheduled for our Bariatric Surgery Nurse and Nutrition Consultation Class conducted by a registered nurse and registered dietitian. These consultations occur every two weeks and comply with National Institute of Health (NIH) criteria stating that patients have to be well-informed about surgery. A friend or significant other is strongly encouraged to participate in these consultations with you.
Step Three:
After attending the Bariatric Surgery Nurse and Nutrition Consultation Class, you will be scheduled for a pre-surgical consultation, your surgeon will:
Review your medical history
Perform a pre-surgical examination
Evaluate and determine if you are a suitable surgical candidate (any additional studies and/or consultations will be ordered at this time if needed)
Answer any and all of your questions
Step Four: If you are paying cash, we can schedule you for a medical clearance necessary for your surgery. If you will be relying on your insurance company for payment, your surgeon will dictate a letter of "medical necessity" and we will request "pre-certification" from your insurance provider.
Depending on your medical case and your insurance provider, this process can take anywhere from a few days to several months.
The process also may include providing your insurance company with any other documentation they request from our office, from other physicians or clinics involved in your medical care, and/or directly from you. Our experienced staff will work hard to obtain insurance approval for your procedure and we are always happy to answer any questions you may have during this period.
Once we have received written insurance approval, we will schedule you for a medical clearance for your surgery. We also will schedule you for a final evaluation with your surgeon.
Step Five:
A surgery date will be determined during your final office visit with your surgeon and the necessary paperwork will be completed.
Step Six:
Surgery, recovery and the beginning of your new life!
