General Surgery Prior Authorization and Denial Guide
Prior authorization requirements, denial patterns, and appeal strategies for general surgery, including site-of-service documentation requirements, bariatric surgery prior authorization criteria, cholecystectomy documentation standards, hernia repair coverage criteria, and thyroid and parathyroid surgery prior authorization. Grounded in Aetna Medical Policy for bariatric surgery, UHC CDG General Surgery, CMS coverage rules, and SAGES clinical guidelines.
Bariatric surgery: Roux-en-Y gastric bypass (CPT 43644, 43645) and sleeve gastrectomy (CPT 43775) require prior authorization from all payers. Standard documentation requirements include BMI ≥40 or BMI ≥35 with qualifying comorbidities (T2DM, OSA, hypertension, hyperlipidemia), documented participation in a medically supervised weight loss program (typically 3–6 months), psychological evaluation clearing the patient for surgery, nutritional consultation, and bariatric surgery-specific pre-operative workup. Aetna and UHC require the medically supervised program to be documented with dates and outcomes — unsupported statements of prior attempts are insufficient.
Laparoscopic cholecystectomy (CPT 47562) and open cholecystectomy (CPT 47600) do not typically require prior authorization for acute cholecystitis or symptomatic cholelithiasis, but some commercial payers require PA for elective procedures. Documentation must include ultrasound or CT confirming gallstones or biliary pathology and symptom documentation. Hernia repair (CPT 49505–49590, 49561) requires documentation of the hernia type, size, and symptoms — reducible hernias without symptoms are less clearly covered by some payers, particularly for laparoscopic approaches. Incisional hernia repair following prior surgery requires documentation of prior surgical history and current hernia characteristics.