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.
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)
- First Health
- One Health
- Tufts Health Plan
- United Healthcare
- Oxford Health Plan
- American Family Insurance
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.Source: lapband.obeseinfo.com