If you're going to pursue Lap BandŽ System weight loss surgery, there are a number of options for you to pay for the procedure. Insurance and financing may seem complicated, but here is some crucial information that can help you make the best financial decision. Please be sure you check with your Lap BandŽ System surgeon to confirm what options are available to you.
Click on the icon to view a PDF file of the medical expense tax deductions brochure Will My Insurance Cover the Lap BandŽ System Procedure? - Lap BandŽ Adjustable Gastric Banding System surgery was approved by the Food and Drug Administration (FDA) on June 5, 2001, (for details, go to http://www.fda.gov/cdrh/mda/docs/p000008.pdf)
- To find out if your policy covers weight loss (or bariatric) surgery, refer to the policy package that you received after paying your first premium, or that was provided by your employer.
- If you don't have a copy of your health benefits, contact the Human Resources department of the employer which provides your coverage.
- Typically, there are two sections that outline the extent and limits of your coverage. Look for "What is Covered" or "Covered Expenses". These are the expenses that the insurance company will pay.
- The other sections to check are "What is Not Covered" or "When the Plan Does Not Cover Benefits".
- Look for any reference to exclusion of coverage for weight control, for the treatment of obesity, for surgical weight control, or for the complications of weight control or weight control surgery.
- Some policies will not cover any bariatric surgery. Other plans may have restrictions about which surgeries and what they will 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 the surgery is covered when medically necessary, then you will be covered if you meet national guidelines for the care of morbid obesity.
- You may also get partial coverage - this can include: tests, or by having another approved abdominal surgery done at the same time, thereby covering some of the hospital and anesthetic fees.
Below is a partial list of insurance companies that are known to either partially or fully cover Lap BandŽ System surgery. Please note that this list is not a guarantee that you will be covered - this is for informational purposes only.
- Aetna
- American Family Insurance
- Blue Cross (in many states)
- Cigna First Health
- Health Net
- Humana
- One Health
- United Healthcare
In addition to the list provided, on February 21, 2006, the Centers for Medicare and Medicaid Services (CMS) published a National Coverage Determination for bariatric surgery. They determined that they would cover the Lap BandŽ System procedure, along with Gastric Bypass and Biliopancreatic Diversion (BPD). Any Medicare beneficiary, including those over the age of 65, is covered for surgery as long as he/she meets the normal criteria for surgery. However, please note that the Medicare beneficiary's procedure of choice must be performed at either an American Society for Bariatric and Metabolic Surgery (ASMBS) accredited Center for Excellence or and American College of Surgeons (ACS) Level I Bariatric Surgery Program. If your facility is not accredited by either of these bodies, payment for the procedure may not be made by Medicare. Check with your surgeon's office before you schedule any procedure.
Insurance Authorization Requirements
It's routine that you will probably require prior authorization from your insurance company for weight loss surgery. You will likely need to send a "Letter of Medical Necessity" and personal weight loss history stating why significant weight loss is medically critical for you. This letter usually includes:
- Your weight (should be at least 100 pounds overweight; a BMI of at least 40; or a BMI of 35+ with a weight-related medical condition.
- A list of serious medical conditions associated with obesity such as Type 2 diabetes, sleep apnea, hypertension, or any other condition from which you suffer.
- The number of years that you have been overweight (which should be at least five years).
- The number and type of failed weight loss programs you have tried in the past.
A good way to significantly improve your chances of being approved for Lap BandŽ System weight loss surgery insurance is to create a document or package listing all your previous weight loss attempts (on your own or with medical supervision) and the results. You should include any commercial diets that you've been on, as well as your medical records that document your weight loss efforts.
Click on the icon for a sample Letter of Medical Necessity. Appeals
If your request for prior authorization for the Lap BandŽ System surgery is denied by your insurance company, you may have the opportunity for a limited number of appeals of this decision. The process varies according to the plan, so be sure to check your insurance company's specific appeal policy. Generally, you can appeal if your denial is based on the following reasons:
- The Lap BandŽ System is investigational
- The Lap BandŽ System is experimental
- The insurance company has no previous knowledge of the Lap BandŽ System
- You did not meet the criteria for the surgery.
An effective appeal should:
- Answer the specific reason(s) for the denial
- Include supporting documentation
You can also contact an experienced lawyer to help you with the appeal. More information about legal help can be found at:
Click on the icon to view a PDF file of the appeals brochure. Insurance Alternatives
There are circumstances where health plans will not cover the Lap BandŽ System surgery, regardless of your medical necessity. In this situation, patients often feel they have exhausted their options. This is not the case. There are other financing options you may want to consider.
- Out of Pocket Payment - depending on your personal financial situation, you may want to consider a lump sum payment.
- Patient Financing
- Loans - there are special medical financing companies that you may contact. They offer easy access and a full range of payment plans.
- The Lap BandŽ System Patient Financing Program
The Lap BandŽ System Patient Financing Program
Your doctor may also be a participant in the Lap BandŽ System Patient Finance Program -- a program that links Lap BandŽ System patients with CareCreditŽ, a GE Money company. If not, your doctor can easily enroll in this program by contacting his or her Lap BandŽ System Account Manager.
CareCreditŽ works just like a credit card, but is exclusive for healthcare services. You can finance 100% of the procedure cost, insurance co-pay or deductible and you will receive notification of
approval within minutes. You can be approved for a
loan with monthly payments up to 84 months. Simply go to
CareCredit.com for more details and to learn how to apply.
You should weigh the advantages and disadvantages of each of these options and carefully make the decision that is best for you. If you still have questions regarding these options you should seek advice from a financial professional.
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