The Pre-approval Process
Once you have determined the type of coverage you have and understand your policy, you will want to get pre-approved (or receive a prior authorization) for your procedure. Pre-approval is almost always required for weight-loss surgery. This is an excellent way to make sure that this procedure is covered under your contract.
Typically, your surgeon’s office will submit the necessary information to your insurance provider in order to seek pre-approval. However, if they do not, you will want to seek pre-approval on your own.
When seeking pre-approval, it is best to contact your insurance provider in writing and request a determination of your coverage amount prior to your procedure (to ensure receipt of your letter, send it by certified mail and file a copy of the individual’s signature who accepted it). Again, make sure to request this in writing (see a sample letter here).
Make sure to follow-up with your insurance company. If you have not received anything within a week of speaking with them, call back and confirm your materials have been received.
Insurance Provider and Reviewing Claims
Your insurance provider very carefully reviews your claim and looks for two main things:
- Which procedure/benefit are you trying to access
- Reason why you are accessing this benefit (if available based on your policy restrictions/exclusions)
The procedure/benefit you are trying to access will be coded using a CPT code. These codes originate from the American Medical Association and allow physicians to record the treatments provided to allow for processing of your claim.
The “reason” for the treatment will be represented by an ICD-9 code. This tells the insurance company your doctor’s diagnosis and why treatment is needed. These are the codes and processes used to determine whether or not a claim will be covered under your policy.
Difference Between CPT Codes and ICD-9 Codes
CPT Code : This code indicates the procedure/benefit you are trying to access. These codes allow physicians to record the treatments provided to allow for processing of your claim.
ICD-9 Code : This code indicates the “reason” for the treatment. These codes tell the insurance company your physician’s diagnosis and why treatment is needed. These codes also determine whether or not a claim will be covered under your policy.
If the codes were incorrect, obtain the correct codes and a letter from your doctor, and resubmit your claim. An incorrect coding error could impact your claim and deny reimbursement.
Sample CPT and ICD-9 Codes
Please note that the below codes are provided as an example. Codes often change, so check with your surgeon’s office for the most current codes.
Laparoscopic Gastric Bypass/43644
Open Gastric Bypass/43846
Adjustable Gastric Banding System/43770
Laparoscopic Sleeve Gastrectomy/43775
Biliopancreatic Diversion with Duodenal Switch/43845
Degenerative DZ Wt. Bearing Joints/715.09
Chronic Respiratory Disease/519.9
Chronic Venous Insufficiency/459.81
Urinary Stress Incontinence/788.32/625.6
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