Bariatric surgery services
Applies to:
All plans
Definition
The most common bariatric surgery procedures are gastric bypass, sleeve gastrectomy, adjustable gastric band, and biliopancreatic diversion with duodenal switch.
Medical policy
Bariatric surgery coverage
Weight-loss surgery may not be covered, especially by self-funded group plans and individual plans. Verify the member's coverage by using Member Inquiry to check the Additional benefits for the Certain surgeries benefit, or call the Provider Helpline.
Non-standard cost-sharing
If/when commercial employer group and MyPriority® individual plans cover certain surgeries, these surgeries may be covered at a different cost-sharing level than our standard benefit coverage levels.
To verify member cost sharing and coverage, use the Member Inquiry tool and look in the Additional benefits drop-down menu for Certain surgeries benefit information.
Bariatric surgery authorizations
Starting Oct. 31, 2022, we’ll require the pre-surgical evaluation to cover specific areas related to a member’s drug use habits to meet prior authorization requirements. See the medical policy for details and a sample survey.
- Participating providers: Use our online authorizations tool to go to GuidingCare.
- Non-participating providers: Use this Medical Authorization form.
Bariatric surgery billing
See the medical policy for codes that may apply and codes not covered.
Check eligibility & coverage
Authorization tools
In prism, you can request a new authorization or check an auth's status.