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.
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