Will Insurance Cover Bariatric Lap-Band Surgery?

Bariatric Lap-Band surgery is one of the safest surgeries to help with weight loss, but it can also be expensive too (as with most any type of surgery). For this reason, many insurances (such as Blue Cross (in some states), Humana, One Health, Medicaid, First Health, Tufts Health Plan, United Healthcare, Oxford Health Plan, and American Family Insurance) have been known to cover for bariatric care. If covered, insurances will either cover for complete care or partial care.

If you are not covered by your insurance company, it may not hurt to talk to your employer. Lots of times it is the employer that decides what will or will not be covered for their employees. It is usually not difficult for an employer to make a change in an employee's insurance package. It is, however, very difficult for an employee to make a change since it is the employer that purchases the insurance packages in bulk and therefore, already has a deal set up with the insurance company.

Not even bariatric centers can get insurance companies to change a policy that is already written, no matter how qualified the person is for getting a bariatric procedure done. However, it will be much easier for your employer to change your insurance policy if you do qualify for bariatric procedures because of medical reasons.

Even if your insurance won't cover for bariatric care, there are other options that are usually available. Many centers have "out-of-network" benefits you can take advantage of, and financial plans through third parties that will help allow you to pay. Bariatric centers will generally try to work with you and your financial needs.

Lap Band Surgery - Appealing Insurance Denials for Bariatric Surgery

It can be very discouraging if your insurance company denies the pre-authorization request for coverage of lap band surgery. If you receive a denial, however, don't give up! Instead, appeal the decision. Like many other lap band patients who were initially denied coverage, you too may find that it is possible to gain approval through the appeals process.

Denial of Coverage Notification

When you receive a notification of denial, the first step towards filing an appeal is to determine why the insurance company denied your request. Once you know the exact reason why coverage was denied, then you can proceed with gathering the information needed to overturn the initial decision.

When you follow-up with the insurance company for details, be polite yet persistent. Not only do you want to find out why the surgery was denied, but you want to find out what information the insurance company requires for approval. The insurance company may not make it easy for you, but don't let that stop you from working through the appeal process.

Paperwork and Documentation

Many pre-authorization requests for coverage of bariatric surgery are denied simply because of incomplete paperwork and lack of proper documentation. While you may know that you have struggled with obesity for years and have tried to lose weight with diet, exercise and medically supervised plans, the insurance company will not know that unless you provide them with all the "evidence" to this effect, including documentation of doctor visits for weight loss, receipts of diet and exercise programs, and medical history records. Since there is no such thing as providing too much relevant information, be thorough and submit all the proof you have of previous weight loss attempts. The documentation you provide to the insurance company can make a difference as to whether or not you are granted coverage for surgery.

Meeting Patient Criteria and Medical Necessity

Coverage for lap band surgery often depends on whether or not an individual meets The National Institutes of Health (NIH) patient criteria for weight loss surgery and if the procedure is considered a medical necessity. Both of these conditions can be established by your doctor and presented to the insurance company in a Letter of Medical Necessity. The statement your doctor provides to the insurance company about your obesity and weight related health problems is very important in showing your insurance company the medical necessity of weight loss surgery. Your doctor should be more than willing to write a letter to your insurance company as a way of helping you present your case for coverage of lap band surgery, both in the initial request and in the appeals process.

Appealing an Exclusion for Weight Loss Surgery

Even if your insurance plan excludes "obesity surgery" or "treatment of obesity" it may still be possible to appeal and win. Bariatric surgery has been shown to be an effective treatment for many other diseases, including type 2 diabetes, hypertension (high blood pressure), and obstructive sleep apnea. Since these diseases are usually covered by health insurance, the appeal would be based on your doctor's opinion that bariatric surgery is the best method for treating your health problems. Documentation should be presented to the insurance company showing that other treatment methods have not been effective in controlling or curing the disease.

Writing An Insurance Appeal Letter

When you are informed of a denial there is usually a date limit to respond. While it is important to appeal within a timely manner, it is also important to respond effectively. When appealing, write a letter that is factual and persuasive, yet pleasant and polite. Make sure you include all the relevant information and include the supporting documentation to establish patient criteria and medical necessity. Make copies of everything you send for your own records and then send the package with tracking information for proof of mailing.

Is Lap Band Insurance Something You Should Look for?

If you are looking at getting the lap band procedure, you know that while this is one of the more inexpensive procedures you can have done, it is still something that you need to budget for. That being said however you may also want to look and see whether or not you can get insurance coverage for the specific procedure.

The reason for this is that unlike other surgeries which may be considered cosmetic, lap band can also be considered something that will save your life especially if you have been struggling with your weight and things like your cholesterol or your heart over time. The key here of course is to ensure that your documents it history to show your insurance company of what weight-loss procedures you have tried before.

You also need to ensure that you have a solid presentation on not only the general benefits of the lap band surgery but also how it can help you specifically. You want to ensure that your insurance company understands that this will in fact save your life. Something else to consider of course is whether or not you fact need lap band surgery insurance in the first place. You may decide that the amount that your insurance company will cover is not necessarily worth the hassle of trying to convince them in the first place. Or, you may decide that you have enough cash on hand that you can just pay for all of once and not worry about having insurance pay for either. That of course is up to you however, insurance companies are there to help you when you need it especially with regards to things like your help at home. That being said, you may also decide that it is just too much hassle to search for various companies that will cover the cost or at least partial cost of the surgery.

Ultimately, it is up to you to decide whether lap band insurance is something you need.