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.

• Claim Requirements
• Insurance Coverage
• Preoperative Steps to Bariatric Surgery
• Postoperative Care and Follow-Up

Claim Requirements

Currently, we offer one bariatric surgery procedure: laparoscopic Roux-en-Y gastroenterostomy. It is a combination of restrictive and mal-absorptive procedures and restricts or limits how much one can eat.

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 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 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 should be documented.
Back to top

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 only perform surgery at Stanford University 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 Stanford University Hospital as an approved facility.

Back to top

Preoperative Steps to Bariatric Surgery

1. Once you contact your health insurer to determine which bariatric services, if any, it will cover, we will make an appointment for you to attend a shared medical appointment (SMA) for a bariatric surgery consultation. An SMA is a medical appointment in a group setting with approximately eight to 10 people. This format allows the bariatric surgeon to provide you and other potential bariatric surgery patients with information about the procedure and the lifestyle changes it requires. The surgeon will consult with you individually in a private setting.
   
   Please call General Surgery Department at 650-853-2985 to be scheduled for an SMA.
   
   
2. 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.
   
3. 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.
4. 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 the gastric bypass surgery. 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.
   
5. Once authorization is approved, the surgery will be scheduled within 90 days. Please call General Surgery Department at 650-853-2985. The nurse coordinator will help you with preparation.
   
   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, abdominal ultrasound and upper GI exam.

Back to top

Postoperative Care and Follow-Up

We expect you to complete the postoperative medial follow-up program, which includes visits at one week, one month, two months, three months, six months and 12 months after surgery and every year thereafter. These visits are typically done in a group setting.

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

Back to top