Prior Authorization
Humana Prior Authorization for CPT 43775
Bariatric surgery procedures · Standard commercial plans
Source
Humana Commercial Preauthorization and Notification List (July 2024)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
Humana requires prior authorization for sleeve gastrectomy. Criteria: BMI >=40, or BMI >=35 with at least one serious comorbidity. Must complete 3-6 months supervised weight management (duration varies by plan), psychological evaluation, nutritional counseling, and preoperative medical clearance. Medicare Advantage plans follow NCD 100.1 criteria.
Documentation checklist
- ✓BMI documentation (current and 5-year history)
- ✓Supervised weight management program records
- ✓Psychological evaluation
- ✓Nutritional counseling documentation
- ✓Medical comorbidity records
- ✓Preoperative testing
Submission channels
Phone
1-800-444-9137Fax
1-877-418-05062026 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). Humana'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 documentation (current and 5-year history), Supervised weight management program records, Psychological evaluation….
- 3Submit via phone or fax, or the payer portal.
- 4Document the reference number and follow up within 5 business days if no determination is received.
FAQ
- Does Humana require prior authorization for CPT 43775?
- Yes. Humana requires prior authorization for CPT 43775 (Bariatric surgery procedures) under Standard commercial plans per its published clinical policy.
- What documentation does Humana require for CPT 43775?
- BMI documentation (current and 5-year history); Supervised weight management program records; Psychological evaluation; Nutritional counseling documentation; Medical comorbidity records; Preoperative testing
- 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 Humana are typically negotiated against this benchmark.
- What if Humana 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 Humana PA lookups
CPT 43775 prior authorization by payer
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