Insurance Coverage for Weight Loss Surgery

If you are considering weight loss surgery but are unsure whether your medical insurance covers bariatric procedures, our team has provided the form below to help you better understand your benefits. In addition to learning about your coverage, this form can help you discover whether certain requirements are needed prior to getting approval for surgery.

Since insurance can often feel like a complicated step in the bariatric surgery process, we strive to help patients get answers as soon as possible. We recommend filling out this online form prior to your consultation to help you plan for your treatment. After your consultation, our team will contact your insurance to make sure the details on your form are accurate.

If you have any questions, please don’t hesitate to reach out to us.

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Today's Date

Name

Phone

Questions to Ask Your Insurance Representative

Contact the customer service phone number on the back of your insurance card and ask them the questions below, filling out the answers as you go.

Does my plan offer coverage for bariatric surgery? Laparoscopic Lap Band 43770, Laparoscopic Sleeve Gastrectomy 43775, Laparoscopic Gastric Bypass 43644, Laparoscopic DS 43659. Revision 43659. Diagnosis: Morbid Obesity E66.01

Yes

No – If you are told no, bariatric surgery is excluded from your plan.

Do I need to go to a special distinction or insurance-certified bariatric surgery center?

Yes – Please specify below

If you selected Yes above,please specify your answer here:

Will I need to follow a pre-operative diet or nutrition requirement?

Yes - Please fill answer below

For how many months will you require follow a pre-operative diet or nutrition? If this is necessary, our team can help you obtain the proper documentation and ensure your surgery is approved. This is a common requirement.

Are there any other details I should know about my medical policy?

Rep's Name

Call Reference #

Please note: This worksheet does not guarantee you have coverage for or are approved to undergo bariatric surgery. If your plan offers coverage for weight loss surgery, that does not mean you have approval for a specific procedure. After your consultation, our team will contact your insurance to verify your benefits and request approval for surgery.

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