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Weight Loss Surgery - Insurance

Insurance Requirements Overview

 
Many insurance policies cover surgical treatment of morbid obesity. We will assist you with a preliminary verification of insurance benefits. This will be discussed at your initial office consultation after our surgeon has determined that you are a surgical candidate. During this financial consultation, we will also review the specific requirements your insurance company has prior to approving your surgery. We do work with most types of insurance.
 

I. First, Clinical Clearance; Then, Insurance Approval.

Once you’ve made the decision to pursue weight loss surgery, we understand you are anxious to get the process started and move towards surgery as quickly as possible. However, each component of the clinical clearance process is designed to help you achieve and sustain your weight loss goals safely. These items are mandated by the surgeon and must be completed before your final insurance approval can take place.
 
Clinical Requirements:
 
  • Medical Clearance by Primary Care Physician 
  • Medical Clearance by Specialist, if applicable (ie. Endocrinologist, Orthopedist, Cardiologist)
  • Nutritional Evaluation
  • Mental Health Evaluation and Clearance
  • Exercise Consultation
  • Lab results 
  • Depending on your medical history and comorbidities, additional testing such as a Sleep Study or Endoscopy may also be required for surgical clearance.
 
Once our surgeon has clinically cleared you for surgery and you have satisfied insurance requirements, we can submit your documentation for insurance approval for surgery. 
 

II. Insurance Requirements 

Each insurance company, and even each individual insurance policy, has specific requirements that patients will need to complete prior to being considered for bariatric surgery approval. Some, all, or none of the following requirements may be necessary. Again, the specific requirements of your insurance company and policy will be reviewed with you by our financial counselor at your initial office consultation. 
 
Potential Insurance Company Requirements:
 
  • Medical Clearance (by Surgeon and Primary Care Physician)
  • Medical Clearance by Specialist if applicable (ie. Endocrinologist, Orthopedist, Cardiologist)
  • 6 Consecutive Months Medically Supervised Weight Loss Program
  • 3 Consecutive Months Multidisciplinary Weight Loss Program
  • Nutritional Evaluation
  • Mental Health Evaluation and Clearance
  • Lab results 
  • Weight History documentation by a Medical Provider (2 to 5 year history)
 
We work with you to compile this documentation and we submit it to your insurance company on your behalf. Upon submission, the Insurance Reviewer can take 3-14 days before issuing final determination for authorization. 
 
Once insurance approval is granted, our Surgical Coordinator will contact you to schedule your surgery date.
 
Sibley Self-Pay Package 
 
If you don’t have insurance or your insurance does not cover weight related services (Policy Exclusion), we can assist you with identifying financing options to help you achieve your weight loss goals. In general, self-pay patients are able to more quickly advance towards surgery because they do not have to compile additional documentation for the insurance company and wait for insurance approval. However, all patients MUST satisfy the clinical criteria outlined above before being scheduled for surgery. Typically, self-pay patients can be scheduled for surgery within 4-8 weeks after their initial consultation.
 

 III. Time to surgery varies for each patient depending on your Insurance and Motivation.

You will notice that many (but not all) of the items required for clinical clearance overlap with insurance requirements. It typically takes 4-6 weeks for patients to get clinical clearance for surgery. Insurance approval can take anywhere from 3-14 days. Typically, our patients proceed to surgery 6-8 months after starting our program. Highly motivated patients take initiative in gathering documentation of past weight loss attempts, medically supervised weight loss, and other documentation by primary care physicians or specialist doctors recommending surgical weight loss as treatment for morbid obesity. 
 
Documentation of Medically Supervised Weight Loss (MSWL) attempts are often required by insurance companies. Again, the specific requirements of your insurance company and policy will be reviewed with you by our financial counselor at your initial office consultation. 
 
Medically Supervised Weight Loss (MSWL) Documentation Requirements:
 
Some, all, or none of the following requirements may be necessary. 
 
  • 6 consecutive months of a MSWL program             
  • Two, 3 consecutive months of a MSWL program 
  • Completed within 2-5 years of projected surgery date 
  • Performed by Medical Professional (ie Physician, Nurse Practitioner, or Dietician/Nutritionist)
  • Monthly progress notes documenting weight loss attempts such as:
  • Monthly visits with a nutritionist
  • Prescription Weight Loss Medication Program with office notes
  • Weight Watchers or Jenny Craig with documentation / booklet / receipts
  • In lieu of monthly progress notes, SOME insurance carriers will accept a strong summary letter outlining previous weight loss attempts 
 
Insurance companies will not accept self-directed programs such as Atkins or South Beach. In addition, regular doctors’ visits are also not accepted as proof of MSWL. 
 
If you do not have documentation, you can complete Medically Supervised Weight Loss with our Center.
 
 
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