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Redwood City Center

If you believe you qualify for weight loss surgery from answering these questions, you may also have questions about whether or not you are covered by insurance, since self-paying cash for all the visits, surgery, hospital and anesthesia costs may add up.

Although the health care community has long recognized a clear connection between obesity and many devastating health conditions, it has taken a number of years for health insurance carriers to acknowledge obesity as a disease. As more and more people are having bariatric surgery for morbid obesity, the terms under which insurance carriers will cover bariatric surgery have become very specific. Therefore, you must follow insurance guidelines carefully in order to ensure your surgery will be authorized and approved by your insurer.

Before you begin planning for bariatric surgery, check with your insurer to determine coverage of preoperative bariatric consultation, nutrition consultation, psychiatric evaluation and surgery

Financial Considerations
Insurance Pre-Authorization Requirements
Insurance Coverage
Preoperative Steps to Bariatric Surgery
Postoperative Care and Follow-Up

Financial Considerations

What about insurance?
Patients should be aware that not all insurance plans have benefits to cover weight loss surgery. Some employers do not provide this coverage. In addition, some insurance plans cover one type of surgery and not another. Also, there may be out-of-pocket expenses and these costs can vary. Patients should contact their insurance company to confirm their policy benefits for weight loss surgery and the type of surgery covered. Certain insurance companies even further restrict you to a particular hospital to have your surgery.

Specifically, call the customer service number on the back of your insurance card. Ask if your personal policy covers the Surgical Treatment for Morbid Obesity which has the diagnosis code 278.01. If they do, ask your insurance company to send you the Medical Policies for this treatment so that you can bring in a copy to show us what your specific plan covers. This will greatly expedite getting pre-authorization for your procedure.

If you want to know whether or not your plan covers a specific procedure, ask the Customer Service representative about the one you are interested in and give the representative the procedure code to look up:

Laparoscopic adjustable gastric banding (LAP-BAND® System or REALIZE™ Band) – CPT Code 43770
Laparoscopic Roux-en-Y Gastric Bypass – CPT Code 43644
Laparoscopic Restrictive Vertical Sleeve Gastrectomy – CPT Code 43843
Revision Bariatric Surgery – CPT Code 43848

It's best to ask the insurance company about which surgeries are covered by your personal benefit plan before you even call Jennifer Padilla, our bariatric surgery coordinator, at 650-853-2331 to make an appointment for a free orientation so you know your options. Again, some employers do not purchase health insurance policies that include Bariatric Surgery, and some policies do not include the Laparoscopic Restrictive Vertical Sleeve Gastrectomy, or Sleeve Gastrectomy, at this point in time. Policies differ even among members of the same Health Insurance Company.

We do have Self Pay options for those patients who do not wish or cannot use Health Insurance to pay for Bariatric Surgery. Please ask the Bariatric Coordinator about these plans .

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Insurance Pre-Authorization Requirements

For your weight loss surgery to take place, if you are using insurance, pre-authorization must be obtained. Our program will help with this process. Each insurance plan has different requirements.

You must meet the following criteria to qualify for the surgical procedure:

Participate in a weight management program for at least two to five years and have your participation documented by a physician, registered dietician or weight management specialist; and
Have a Body Mass Index (BMI) of 35 kg/m2 with at least one co-morbid condition related to obesity such as diabetes, sleep apnea, hypertension, high cholesterol levels and/or gastroesophageal reflux disease; or have a BMI greater than 40 kg/m2 with or without co-morbid conditions and previously unsuccessful medical treatment for obesity.

Note: For individuals with a BMI of 35 kg/m2 to 39.9 kg/m2 with at least one co-morbid condition that has been diagnosed and treated by a physician, all medications used to treat these co-morbid conditions must be documented. For individuals with sleep apnea, the severity of sleep apnea must be documented and usually CPAP settings are required.

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Insurance Coverage

HMO insurance usually covers bariatric preoperative consultation, nutrition consultation, psychiatric evaluation and surgery, but be sure to check with your health insurer to determine specific coverage. PPO coverage varies. Medicare covers medical preoperative visits, but patients may have to pay out-of-pocket for other services, such as nutrition consultation.

PAMF's bariatric surgeons perform surgery at Sequoia Hospital, Stanford University Hospital, and Menlo Park Surgical Hospital at this time. Currently, PAMF is unable to offer surgical services for MediCare, as the Centers for Medicare and Medicaid Services does not recognize these sites as an approved facilities.
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Preoperative Steps to Bariatric Surgery

Once you contact your health insurer to determine which bariatric services, if any, it will cover, we will make an appointment for you for a bariatric surgery consultation with Dr. Feng.

Please contact Jennifer Padilla, our bariatric surgery coordinator, at 650-853-2331. She will help schedule an initial consultation appointment with Dr. John Feng for an evaluation after confirming your qualifications. Not every patient is a candidate. Please leave a message if you get her voicemail and leave your name, contact phone number, and the best time to reach you during business hours.

You will then be registered as a patient on the phone, if you aren't already one at PAMF, and scheduled at the earliest date possible. Information will be sent to you regarding our location, information about the procedures and a medical and weight history questionnaire. Please make sure you fill out this extensive questionnaire before the day of your appointment. You may have to do some digging to answer some of the thoughtful questions.

After your consultation with Dr. Feng, preoperative evaluations will be ordered to include the following:
You will be referred to PAMF's Nutrition Department for a consultation. Please call the Nutrition Department at 650-853-2961 to make an appointment.
- HMO: Patients are required to undergo six months of medically supervised weight management nutrition visits with a dietitian.
- PPO/medical/self pay: Patients are required to undergo three months of medically supervised weight management nutrition visits with a dietitian.
A two-hour bariatric surgery nutrition class is included and required for all patients. Diabetes nutrition counseling is also a component of the nutrition education.
After you've completed your nutrition visits with the dietitian, a physician or nurse will place a referral for psychiatric evaluation. Please call Psychiatry and Behavioral Health Department at 650-853-4726. Please do not call the department until approval is received.

The Psychiatry and Behavioral Health Department will need to know what type of mental health specialist (M.D., Ph.D., LCSW and MFT) has been approved for the psychiatry evaluation and the effective dates of your authorization.

If you have a PPO plan, we are unable to bill the medical portion of your plan for the bariatric psychiatric evaluation. Patients with PPO plans can do one of two things:
- Contact the insurance carrier and have it recommend a mental health provider that is in-network and covered by the plan
- Elect to be seen by a PAMF provider and self pay out-of-pocket for the visit. Then, you may request reimbursement from the insurance carrier directly yourself.
Prior authorization will be submitted after completion of all of the above. We will review all the reports and submit the insurance authorization approval for your planned surgical procedure. The insurance reply may take anywhere from a few days to four weeks.

The authorization for surgery must be obtained in writing from the insurance company. If the authorization is obtained, this means the insurance company approved the treatment and will cover the cost of surgery as outlined in the specific plan. It is interesting to note that their authorization letter states that they do not guarantee anything.
Once authorization is approved, the surgery will be scheduled within 90 days, often much sooner. Please contact Jennifer Padilla at 650-853-2331 who will help you with your preparation for surgery.

Before your surgery, you will need to schedule an appointment with your primary care physician and surgeon for a preoperative medical history and physical exam. Your doctor will order any necessary preoperative tests, such as blood tests, EKG, chest X-ray, upper GI exam, cardiac stress tests, etc. Completing these tests in a timely fashion is essential to a smooth transition to your surgery day.

Postoperative Care and Follow-Up

We expect you to complete the postoperative medical follow-up program, which includes visits at 2 weeks, one month, three months, six months and 12 months, 18 months, and 2 years after surgery and every year thereafter with Dr. Feng. Support group meetings are essential also on a monthly basis, especially in the first year.

Postoperative follow-up nutritional and behavioral/psychological therapy sessions are also highly recommended so that you may continue to make lifestyle improvements for a successful outcome.
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