Lap Band Surgery - Will Insurance Cover the Cost?

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.

Don't Go It Alone

Your chances of insurance approval is much greater if you have the support of a qualified surgeon that offers administrative assistance for insurance requests and/or appeals. A surgeon who has considerable experience with weight loss surgery and also knows what information to provide to the insurance company is much more likely to gain approval from the insurance company. It also helps if the medical office has an insurance coordinator that is available to assist you in dealing with your insurance company. If you are still having trouble gaining approval for lap band surgery from your insurance company, you may find it helpful to contact the Obesity Law and Advocacy Center for legal advice.