Many insurance companies will base their approval for weight loss surgery on whether or not the patient meets the criteria set by the National Institutes of Health (NIH).
LAP-BAND® Insurance Coverage
If you have health insurance and are considering LAP-BAND surgery, you will need to find out if your insurance provider covers this procedure and if the surgeon accepts your health insurance. LAP-BAND surgery is an approved procedure in the United States and morbid obesity is a recognized disease and disability. However, insurance coverage will vary from plan to plan and company to company so it is important to talk to the doctors office and hospital as well as the insurance company about coverage.
It is beneficial to contact your health insurer as early as possible if you are interested in weight loss surgery. Many insurance companies will cover the expense, but the approval process can be long and complicated. If you contact your insurance provider and are told that weight loss surgery is not covered, don't get discouraged and don't give up. Many times the initial answer is based on incomplete and mistaken information. There is still a chance that by working diligently together with your primary care doctor, bariatric surgeon, and other legal and medical experts, you may succeed in getting approval thru the appeals process.
Obesity Legal Assistance
It may be appropriate to seek support and legal assistance if you really ought to be granted approval for weight loss surgery but your insurance company refuses to cover it. If you are struggling with your insurance company, you may find the Obesity Law and Advocacy Center a source of useful assistance. You may also want to consider joining the Obesity Action Coalition, a national advocacy group for the rights and needs of obese people.
Patient Criteria for Lap-Band Surgery
Many insurance companies will base their approval for weight loss surgery on whether or not the patient meets the criteria set by the National Institutes of Health (NIH). In fact, many states have laws that require insurance companies to provide coverage for weight loss surgery if these criteria are met. Some of the important recommendations made by the NIH are:
- Patient is diagnosed with clinical severe obesity, BMI >40, or BMI> 35 with co-morbidities such as heart disease, diabetes, hypertension, sleep apnea, or degenerative arthritis
- Patient has suffered from morbid obesity for at least five years
- Patient has failed at non-surgical attempts at weight loss over the years
- Patient is at a high-risk for obesity-associated morbidity or mortality
- Patient is motivated and has an acceptable operative risk
Lap-Band Surgery Insurance Approval
It is usually necessary to have a referral from your primary care doctor and documentation of your weight loss attempts over the years in order to be granted insurance approval for weight loss surgery. The basic items that should be submitted to your insurance company:
- A referral letter from your primary care doctor that establishes a "Medical Necessity" for weight loss surgery. It is important to have the full support of your primary care doctor. In the referral your doctor will include why weight loss surgery is a medical necessity based on your weight and/or BMI, history of being obese over 5 years, have tried and failed at other weight loss attempts, a list of all your medical problems associated with obesity, and that weight loss is a medical necessity.
- Documentation of your weight loss history for the past several years, including receipts and accurate, detailed records related to your weight loss efforts. Include documentation and medical records of all your visits to doctors and other healthcare professionals for obesity-related issues. Include receipts from weight loss programs such as Weight Watchers, Jenny Craig, NutriSystem; diet plans such as Atkins, Zone, South Beach diet; books on weight loss; weight loss medications and prescriptions; fitness clubs; exercise equipment. Include any and all documentation that supports your weight loss efforts.
Sample Insurance Appeal Letter
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