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Insurance
coverage
for
the
Lap
Band
procedure
Insurance coverage
for the Lap Band
surgical procedure
is determined on a
person-by-person
basis. Our team will
assist you with the
procedure as it
relates to
individual insurance
companies, like
First Health, United
Healthcare, Cigna,
Great West or Blue
Cross Blue Shield
Federal. Although the
following general
information is
provided for
educational
purposes, talk to
you surgeon about
your individual
case.
Click here for
gastric bypass
insurance
guidelines.
Insurance
Verification
To determine if your
insurance policy
covers obesity (or
"bariatric")
surgery, refer to
the insurance policy
package that you
have received after
paying your first
premium or provided
through a plan
offered by your
employer.
Typically, there are
two sections that
describe the extent
and limits of
coverage. The first
is usually called
"What Is Covered" or
"Covered Expenses."
These are the
healthcare benefits
for which the
company will pay.
The other section is
"What Is Not
Covered" or "When
the Plan Does Not
Pay Benefits." In
this section, look
for any statement
that the company
excludes coverage
for weight control,
for the treatment of
obesity, for the
surgery for weight
control, or for the
complications of the
surgery for weight
control. Some
policies will
outright exclude
bariatric surgeries.
Others may have
certain parameters
around which
bariatric procedures
they cover and how
much of the costs
they cover. Look for
statements such as,
"Surgery for the
treatment of obesity
is covered when
deemed medically
necessary," or
"Surgery for the
treatment of obesity
is (specifically)
excluded except when
medically
necessary." If this
surgery is a covered
benefit when
medically necessary,
then it should be
covered when
patients meet
national guidelines
for care for morbid
obesity.
You may also see if
you can get partial
coverage for the LAP
BAND System surgery.
There may be a way
to have some of the
tests covered, or
perhaps have another
(approved) abdominal
surgery done
simultaneously
thereby covering
some of the
anesthesia and
hospital fees.
Below is a partial
list of companies
that are known to
either partially or
completely cover LAP
BAND System surgery.
Please note that
this list should not
be construed as a
guarantee that you
will be covered -
it's provided for
informational
purposes only.
-
Blue Cross (in
some states)
-
Humana
-
First Health
-
One Health
-
Tufts Health
Plan
-
United
Healthcare
-
Oxford Health
Plan
-
Medicaid
-
American Family
Insurance
Submission
Requirements
A Letter of Medical
Necessity and
weigh-loss history
are necessary to
obtain prior
authorization for
obesity surgery. A
Letter of Medical
Necessity states why
significant weight
loss is medically
necessary for a
patient and usually
includes the
following
information:
-
Patient's
weight (which
should be 100
pounds or more
above ideal
weight or a BMI
more than 40 or
more than 35
with associated
medical
problems to
qualify)
-
List of medical
problems
associated with
obesity, such
as type 2
diabetes, sleep
apnea,
hypertension,
etc.
-
Number of years
patient has
been overweight
(which should
be at least
five or more)
-
Number and
types of failed
weight-loss
programs
attempted in
the past
-
If you create a
document or
packet listing
all your
weight-loss
attempts
(self-controlled
or medically
supervised) and
their results,
you can
substantially
increase your
chances of
getting
insurance
coverage for
the LAP BAND
procedure. You
should include
any commercial
diets or
medical records
of your
weight-loss
efforts.
Appeals,
Patient Financing
and Self-Pay
If coverage has been
denied upon the
initial prior
authorization
request, you can
appeal by addressing
the specific reasons
why your request has
been denied. Some
patients have been
very successful in
their appeals. Your
surgeon's office
staff can work with
you through this
process.
When insurance
reimbursement is not
available, patient
financing is another
alternative you may
consider. Please ask
your surgeon about
patient financing
programs available
through his or her
office.
If you self-pay, you
may want to discuss
with your doctor and
your insurance
company if this will
affect your
insurance payments
in the future. In
general, insurance
policy may cover
emergency removal of
the band and may
cover post-op
medications such as
prescription
antacids.
In all cases, inform
your primary care
physician (general
practitioner) that
you have a LAP BAND
System implanted.
Additional
Information about
Insurance Coverage
for the Lap-Band
Procedure:
Check
Your
Certificate of
Coverage for
Lap Band
Surgery
Benefits
The first step
is to check
your
"certificate of
coverage" for
benefits or
exclusions of
lap band
surgery.
Insurance
coverage not
only varies
between
insurance
carriers, but
it varies
between
specific
insurance plans
as well. It is
important to
read the
provisions of
your specific
plan with the
insurance
carrier. Even
if your policy
has a weight
loss surgery
exclusion, it
may still be
possible to
appeal.
Check the
Patient
Criteria and
Medical
Requirements
for Lap Band
Surgery
If
lap band
surgery costs
are covered by
your insurance
plan, the next
step is to find
out the patient
criteria and
medical
requirements
for the
procedure.
Insurance
companies often
follow the
National
Institutes of
Health (NIH)
guidelines in
determining
whether or not
a patient
should be
considered
eligible for
weight loss
surgery
coverage. The
NIH guidelines
state that
weight loss
surgery may be
an option for
patients who 1)
have failed
with other
weight loss
treatments and
2) have a BMI
of 40 or
greater, or
have a BMI of
at least 35 and
co-morbidities.
Provide
Documentation
of Previous
Weight Loss
Attempts
Since weight
loss surgery is
considered the
last method of
treatment for
obesity, you
will need to
provide
documentation
to the
insurance
company of
previous weight
loss attempts.
Gather your
receipts and
weight loss
records and
send copies to
the insurance
company. Show
them proof that
you have
exhausted all
other methods
of weight loss
including
commercial diet
programs (such
as Weight
Watchers and
Jenny Craig),
exercise
programs, and
weight loss
medications.
Many insurance
companies may
also require
records for 6
or 12 months of
a continuously
medically
supervised
diet. If you
have not yet
met this
requirement,
you should
start a program
immediately.
The more
documentation
you can provide
the better your
chances of
getting
approval.
Establish a
Medical
Necessity for
Lap Band
Surgery
In order to
verify that you
meet the
patient
criteria for
lap band
surgery, your
primary care
doctor and/or
bariatric
surgeon will
need to send a
Letter of
Medical
Necessity to
the insurance
company. The
Letter of
Medical
Necessity is a
statement of
your height,
weight, BMI,
health
conditions,
medical
records,
previous weight
loss attempts,
psychological
exam results,
medical
necessity for
weight loss,
and your
doctor's
support and
recommendation
for lap band
surgery.
The Appeals
Process - What
to Do When
Coverage is
Denied
While it is
discouraging to
have your
request denied,
don't give up.
Instead, find
out the
specific
reasons for the
denial. Many
times the
reasons for the
denial are
matters which
can be
contested
and/or
satisfied
during the
appeals
process. Many
lap band
patients have
been successful
in the appeals
process, but
you should be
prepared to be
diligent in
meeting the
insurance
company's
requirements
and pressing
for lap band
surgery
coverage. It
may seem like
the insurance
company is
asking you to
jump thru
hoops, but if
you are
persistent you
may succeed in
getting
approval.
Appealing a
Weight Loss
Surgery
Exclusion
If your
insurance plan
has an
exclusion for
weight loss
surgery, it may
still be
possible to get
approval if you
obesity
co-morbidities.
Insurance
policies often
exclude
benefits for
"obesity
surgery" or
surgery for the
"treatment of
obesity." The
basis of the
appeal would be
your doctor's
recommendation
that lap band
surgery is the
best method of
treatment for
your
life-threatening
health
condition, such
as diabetes,
high blood
pressure, heart
disease, or
severe sleep
apnea. Since
these health
conditions are
usually covered
by your
insurance
policy, you may
succeed in
getting
approval for
weight loss
surgery as a
treatment for
one of these
conditions.
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