047 Preauthorization Request Form for Surgical Management of Obesity 2025

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Gastric bypass and other types of weight-loss surgery also called bariatric or metabolic surgery involve making changes to your digestive system to help you lose weight. Bariatric surgery is done when diet and exercise havent worked or when you have serious health problems because of your weight.
Common requirements are: Over age 18 (Some plans allow for surgery under age 18) BMI over 40 or BMI over 35 with high blood pressure, type 2 diabetes, or other risk factors. Documented weight loss efforts over a period of time. Weight loss program mandated by the insurance company. Psychological testing.
Talk to your doctor about your weight loss goals: Discuss your weight loss goals with your doctor and explain why you believe surgery is the best option for you. Be sure to provide any relevant medical information, such as previous weight loss attempts or obesity-related health conditions.
Medical guidelines The surgery may also be an option for an adult who meets these three conditions: BMI of 35 or higher. At least one obesity-related medical condition. At least six months of supervised weight-loss attempts.
Bariatric Surgery Procedures CPT Code range 43770- 43775. The Current Procedural Terminology (CPT) code range for Bariatric Surgery Procedures 43770-43775 is a medical code set maintained by the American Medical Association.