Does Anthem require prior authorization for CPT 43775?

Yes. Anthem requires prior authorization for CPT 43775 (Bariatric surgery procedures) under Standard commercial plans per its published clinical policy.

What documentation does Anthem require for CPT 43775?

BMI and weight history; Supervised weight management records; Psychological evaluation; Nutritional counseling; Comorbidity documentation; Facility accreditation

How much does Medicare pay for CPT 43775 in 2026?

In 2026, the national Medicare allowable for CPT 43775 is $1000.02 in an office setting and $1000.02 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.

What if Anthem denies the PA for CPT 43775?

Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Prior Authorization

Anthem Prior Authorization for CPT 43775

Bariatric surgery procedures · Standard commercial plans

Prior authorization REQUIREDApplies to all statesLast verified January 1, 2026 · Reviewed by the D3rx Clinical Billing Team

Source

Anthem clinical policy

Not medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.

Clinical criteria

Anthem requires prior authorization for laparoscopic sleeve gastrectomy. Criteria: BMI >=40, or BMI >=35 with obesity-related comorbidity. Must complete 6+ months physician-supervised weight management, psychological evaluation, and nutritional counseling. Facility must be MBSAQIP-accredited. Age 18+ for standard criteria; adolescents evaluated under separate pediatric policy.

Documentation checklist

✓BMI and weight history
✓Supervised weight management records
✓Psychological evaluation
✓Nutritional counseling
✓Comorbidity documentation
✓Facility accreditation

Submission channels

Phone

1-800-274-7767

2026 Medicare rate for CPT 43775

Office (non-facility)

$1000.02

Facility

$1000.02

Total RVUs (office)

29.94

Conversion factor

$33.4009

National Medicare Physician Fee Schedule amounts (GPCI 1.0). Anthem's commercial allowable is negotiated against this benchmark — see the full RVU and locality breakdown on the CPT 43775 code page.

How to submit the PA

1Verify the requirement against the current clinical policy linked above.
2Gather documentation: BMI and weight history, Supervised weight management records, Psychological evaluation….
3Submit via phone, or the payer portal.
4Document the reference number and follow up within 5 business days if no determination is received.

FAQ

Does Anthem require prior authorization for CPT 43775?: Yes. Anthem requires prior authorization for CPT 43775 (Bariatric surgery procedures) under Standard commercial plans per its published clinical policy.
What documentation does Anthem require for CPT 43775?: BMI and weight history; Supervised weight management records; Psychological evaluation; Nutritional counseling; Comorbidity documentation; Facility accreditation
How much does Medicare pay for CPT 43775 in 2026?: In 2026, the national Medicare allowable for CPT 43775 is $1000.02 in an office setting and $1000.02 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.
What if Anthem denies the PA for CPT 43775?: Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Other Anthem PA lookups

CPT 17110 CPT 45380 CPT 45378 CPT 11042 CPT 36415 CPT 20610 CPT 62323 CPT 43235

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CPT 43775 prior authorization by payer

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