Presbyterian HCS Weight Loss Surgery - How to Avoid a Denial

Your Presbyterian Healthcare Services weight loss surgery insurance coverage depends on several factors, all of which are reviewed below.

To request a free insurance check, click here to contact a top local surgeon. Alternatively, use the tool below to find out if you have coverage.

CHECK MY
INSURANCE TOOL
1

Choose your plan, state, and insurance company below.

Can’t find your insurance company/plan or have updated info?


Read and click below for additional weight loss surgery insurance details.

Presbyterian Healthcare Services Weight Loss Surgery

READ THIS FIRST

Even if your insurance company covers bariatric surgery in some plans, that does not mean that your specific plan covers it. The obesity surgery approval requirements in this section assume that weight loss surgery is covered by your specific policy.

To confirm whether your specific policiy covers bariatric surgery, click here to contact a surgeon and ask for a free insurance check.

Disclaimer: The information contained on this page may not include all components of your insurance company’s medical policy and/or may not be up to date. Contact your insurance company to confirm all benefits.

In order to be approved by Presbyterian Healthcare Services for bariatric surgery in the United States, you must meet the following criteria:

  1. Be age 18 years of age or older
  2. Diagnosis of Morbid obesity, defined as
  3. Or

    • BMI 35 – 39.9 AND one of the following
      • Cardiomyopathy
      • Congestive heart failure with an ejection fraction of 50% or less than predicted
      • Documentation of previous myocardial infarction requiring hospitalization
      • Documentation of previous myocardial infarction requiring hospitalization
      • Uncontrolled/massive leg lymphedema
      • Obstructive sleep apnea
      • Obesity related osteoarthritis of the lower extremities
      • Pickwickian syndrome or cor pulmonale
      • Obesity related hypertension
      • LDL cholesterol that is clinically significant and unresponsive to medical therapy

    Use this BMI Calculator to check your body mass index…

  4. Appropriate non-surgical treatment should have been attempted prior to surgical treatment for obesity, as evidenced by documented oversight of a structured diet program within the past year supervised by a physician and/or appropriately licensed nutrition specialist, such as a registered dietician or a licensed nutritionist. Physician programs which only provide pharmacological management are not sufficient. Attendance should include, at a minimum, an initial visit for nutritional counseling and one pre-operative follow-up visit. Documented oversight includes records of weight/BMI, dietary program, exercise regimen, behavioral health interventions and pharmacotherapies, if any. The documented BMI at the starting date of the diet program is the BMI used for bariatric surgery.
  5. The member will attend a weight loss seminar presented by the bariatric center where the surgery will be performed; the weight loss seminar explains the various aspects of weight loss surgery, including available surgical options, potential complications and supportive resources.
  6. Behavioral health assessment and clearance by a licensed psychologist or psychiatrist associated with or recommended by the specific surgical program to which the patient has been referred. Evaluation should address potential difficulties the patient may have in adapting to the physical/psychological and other lifestyle/eating changes that will result from the surgery. Specifically, assessment should address:
    • a) The presence of psychiatric risks or active substance abuse that would affect the ability to follow healthcare instruction
    • b) eating patterns and eating disorders that may require psychotherapeutic intervention either pre- or post-operatively
    • c) the patient’s expectations with respect to outcome and whether those expectations are likely to facilitate or hinder adjustment to the necessary behavioral changes
    • Psychological testing should include objective/normed instruments for depression, anxiety, or other psychiatric risks

  7. Bariatric surgery for Presbyterian Medicare program members must follow CMS guidelines and the surgery program for all covered members must be accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program as a Comprehensive Center.

Revision Requirements

Revisions are considered medically necessary if the surgery is to correct documented clinically significant complications (e.g., obstruction, stricture, band slippage, dehiscence, anastomotic leak) of previous bariatric surgery procedure.

If Your Policy Does NOT Cover It: Seek Partial Coverage

You may be able to get part of the costs paid for by insurance even if weight loss surgery isn’t covered. It’s all about how your doctor and hospital submit your claims to your insurance company.

For example, there are many non-bariatric surgery reasons for your doctor to recommend:

  • Cardiology exam
  • Lab work
  • Medically supervised diet program
  • Psychological exam
  • Sleep study

These are ordered for many reasons other than bariatric surgery and may be covered as a result. If your doctor submits one of these claims using a weight loss surgery CPT code (Current Procedural Terminology Code), your insurance is unlikely to cover it. But if your doctor uses a general CPT code, it probably will be covered.

While this may sound “sneaky”, it is an ethical practice. After all, these tests will be beneficial regardless of whether you move forward with surgery.

Presbyterian Healthcare Services Weight Loss Surgery

Before getting into the types of insurance plans, you can cut to the chase by contacting a local bariatric surgeon’s office. Most surgeons will contact your insurance company for free to confirm whether or not you’re covered.

Click here to find a local surgeon and ask them to check your insurance for you for free.

Presbyterian Healthcare Services does cover weight loss surgery, but your specific policy must include it in order for you get it covered.

Following are a list of Presbyterian Healthcare Services plan types and whether they cover bariatric surgery:

Weight Loss Surgery for Health Plans Through Your Work

If you work for a company that has 50 or more full time employees, it is completely up to your employer to decide whether or not to cover bariatric surgery under your health plan.

To find out whether weight loss surgery is covered by your employer’s plan, you have a few options:

Weight Loss Surgery for Individual/Family Plans

The Affordable Care Act (Obamacare) requires all individual and small group plans (less than 50 full time employees) to include weight loss surgery coverage as long as it is considered an “Essential Health Benefit” in your state.

The following states DO currently consider bariatric surgery an Essential Health Benefit (bariatric surgery is covered by all individual, family and small group plans in these states):

Your State Not on the List?

If your state is NOT on the list, then weight loss surgery is probably NOT covered under your plan.

First, contact your local surgeon to be sure. For no charge, their office will contact your insurance company on your behalf to work through the details.

If your surgeon confirms that your policy does not include obesity surgery, you still have several options for making surgery more affordable. See these pages for more information:

    • Arizona
    • California
    • Delaware
    • Hawaii
    • Illinois
    • Iowa
    • Maine
    • Maryland
    • Massachusetts
    • Michigan
    • Nevada
    • New Hampshire
    • New Jersey
    • New Mexico
    • New York
    • North Carolina
    • North Dakota
    • Oklahoma
    • Rhode Island
    • South Dakota
    • Vermont
    • West Virginia
    • Wyoming

Regardless of whether your state is on the list, contact a qualified surgeon to request a free insurance check to verify your coverage.

To review your insurance company’s obesity surgery coverage requirements, click here to jump back up the page.

Weight Loss Surgery for Medicare Plans

All Medicare plans are required to cover the following weight loss surgery procedures:

However, special Medicare-specific criteria apply. Click here to learn more about Medicare bariatric surgery coverage.

Advertisement
Presbyterian Healthcare Services Weight Loss Surgery

Please see below for the procedures Presbyterian Healthcare Services covers, might cover under certain circumstances, and those that are not covered under any circumstances:

Procedures That ARE Covered

Procedures That MIGHT BE Covered

The following procedures MIGHT BE covered by Presbyterian Healthcare Services:

Presbyterian Healthcare Services Weight Loss Surgery

If Presbyterian Healthcare Services denies your weight loss surgery claim and you think it should be covered, consider filing an appeal.

Our Health Insurance Appeals page will get you started, then head over to the Disputes & Appeals page for Presbyterian Healthcare Services to learn how to proceed.

Search the weight loss surgeon directory below to ask a top surgeon about a free insurance check by country and region: