Bariatric Patient Forms and Information - McLaren Northern Michigan

Patient forms and information for those having bariatric surgery

Steps Required Before Surgery at the McLaren Northern Bariatrics

  1. Your Insurance Company: Check with your insurance company to see if bariatric surgery is a covered procedure. They will need the following information:
    • Diagnosis Code:
      • 278.01 (morbid obesity)
    • Procedure Code:
      • 43235 (esophagogastroduodenoscopy)
      • 43239 (esophagogastroduodenoscopy with biopsy)
      • 43644 (gastric bypass)
      • 43770 (gastric banding)
      • 43775 (gastric sleeve)
    • This is considered an inpatient surgery
  2. Financial/Insurance Consultation: A representative from McLaren Northern Michigan will contact you after your seminar attendance to review your insurance and any concerns regarding surgery.
  3. Letter from your Medical Doctor: A letter must be submitted to the McLaren Northern Bariatrics stating any medical conditions caused by obesity (such as high blood pressure, diabetes, reflux, sleep apnea, osteoarthritis, urinary stress incontinence), a statement that you would benefit by this procedure (that is medically necessary), and that your physician is giving medical clearance for you to have surgery. This letter must include documentation that you have been clinically evaluated by an MD or DO who has documented failed weight loss. Some insurance companies require a structured, professionally or physician-supervised weight loss program for a minimum of 6 to 12 consecutive months prior to the recommendation for bariatric surgery.
    • Please mail or fax this letter to: ATT: Bariatrics, 416 Connable Ave., Petoskey, MI Michigan 49770; fax is (810) 600-7263.
    • If no pre-authorization is needed from your insurance company, all clearance letters, including those from your primary care provider and mental health provider, must be received at least 4 weeks prior to surgery. If pre-authorization is required, letters must be received at least 10 weeks prior to surgery. If letters are not received, surgery will be postponed.
  4. Behavioral Assessment: McLaren Northern Bariatrics can provide contact information for local agencies that can perform the assessment, or you may contact someone on your own. Check the cost of this service, as some insurance companies do not cover this service and prices will vary from office to office. This assessment will evaluate the understanding of lifestyle changes that occur with bariatric surgery.
  5. Nutritional Assessment: This must be performed at McLaren Northern Michigan by our dietitian, who is trained in special diet considerations for bariatric surgery patients. Two one-hour sessions will be scheduled prior to surgery. You will also meet with our dietitian after clinic visits throughout your first year. Other appointments may be scheduled on an as-needed basis following your surgery. For additional appointments or questions, call the McLaren Northern Michigan's dietitian's office at (231) 487-XXXX.
  6. Lab Work: An order for blood work will be given to you during your initial screening with the surgeon. Please follow the instructions given with this order. A second set of labs will be done to evaluate health status and must be completed within 30 days of surgery date.
  7. Sleep Study: The physician will evaluate the need for a sleep study and will discuss this with you. This may or may not be required.
  8. Additional clearances: may be required depending on health issues, and will be done at surgeon request.

Physician Supervised Weight Loss Program Documentation

    Request physician order form from McLaren Northern Bariatrics at (231) 487-9786.

Food and Exercise Log Instructions

    To meet insurance requirements for bariatric surgery, your insurance also requires a Food and Exercise Journal.

    See below for a description of how to keep a Food and Exercise Journal.

    Use any one of the following three choices:

    • Northern Bariatrics Food & Activity Diary form (see form example below) to record ALL food intake and activity.
    • Enter electronically using the journals available at or
    • Use the sample journal provided and write your daily food and exercise in a spiral notebook. Continue to keep the journal during your entire supervised weight loss journey.

    Journal entries must be printed and provided to the surgeon and the registered dietitian during your visits.

    The documentation required by your insurance provider cannot be changed by your primary care physician or your bariatric surgeon, even in cases where surgery is recommended by your physician(s) to correct other medical concerns.

    Please contact McLaren Northern Bariatrics at (231) 487-9786 with any questions. We will be happy to help you.