The decision to have lap band surgery may be motivated by health concerns, but it involves financial concerns as well. When selecting a lap band provider, however, it is important to consider more than just cost. Instead, consider the quality and level of care you will be getting for what you pay, find out what expenses and services are included or not included in the quoted fee, and learn more about the factors that affect the total amount you will pay for the cost of lap band surgery.Read more
Lap Band Surgery
Welcome! For those who have struggled with obesity and weight loss, lap band surgery is fast becoming the most popular weight loss surgical procedure. Lap band surgery offers hope of safe, substantial and permanent weight loss to those people who are overweight. Once you are ready to take the step to be banded, however, it can be very frustrating if your insurance company seemingly wants you to jump through hoops to receive pre-approval for the lap band procedure or if you lack the financial resources necessary for weight loss surgery.
The focus of LapBandSurgery.net is to provide you with reliable information and answers to many of the frequently asked questions that lap band patients have regarding lap band providers, insurance coverage, financial assistance, and the cost of lap band surgery.
We hope the information and resources we provide on this site can help you find the answers to your questions as you consider lap band surgery and that you successfully complete the steps leading towards weight loss success.
Will insurance pay for lap band surgery?
Lap band surgery is covered by many insurance companies, but it can vary from company to company and from policy to policy. If you have group insurance, coverage will be determined by the contract your employer has with the insurance company, not with the insurance company itself. Some health plans cover weight loss surgery but some plans have an outright exclusion for morbid obesity surgery.
If you have insurance, find out if your plan includes coverage for lap band surgery. While it is true that lap band surgery was once considered experimental or investigational, it is now accepted as a covered weight loss surgery procedure by many insurance companies including Medicare.
Begining in 2006, a new medical insurance code was added by the American Medical Association (AMA) to cover lap band surgery. This is the code that the doctor submits to the insurance company when sending in a claim for patient services. As defined, code #43770 is for "Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components)."
Even if lap band surgery is a covered procedure, the insurance company will most likely have certain requirements that must be met before pre-authorization approval is given. You will also be responsible for any co-pay, deductible, and co-insurance amounts as specified in your policy.
What is the criteria for insurance to pay for lap band surgery?
Even if your insurance company covers lap band surgery, they will have patient criteria and requirements that must be met for pre-approval authorization. The specific conditions will vary among insurance companies and health plans, but most of them have similar requirements. To get your insurance company to pay for your lap band surgery, you will need to comply with their patient criteria and provide them with the necessary documentation.
Some of the standard requirements that an insurance company will require before giving approval for lap band surgery include:
- A referral letter from your doctor stating the medical necessity of lap band surgery
- Patient BMI over 40, or BMI over 35 with obesity co-morbidities
- Patient history of obesity of five years or more
- Records of medically supervised dieting
- Documentation of previous weight loss attempts
- Psychological Exam
It is common for insurance companies to request documentation of previous weight loss attempts. The insurance company wants to see that you have made legitimate efforts to lose weight. Don't worry about sending too much proof, send everything which supports your weight loss efforts such as records and receipts for enrollment in diet programs (Weight Watchers, Jenny Craig, etc), diet plans (Atkins, NutriSystem, etc), diet books, exercise equipment, gym memberships, weight loss medications and prescriptions, nutritional counseling, and medical visits.
The insurance company needs to be convinced that lap band surgery is indeed a medical necessity and that you have already made serious attempts to lose weight. The better you can present your case to the insurance company the better your chances are of receiving approval for lap band surgery.
Do I qualify for lap band surgery?
Many physicians, lap band providers, and insurance companies, including the Medicare/Medicaid programs, follow the National Institutes of Health (NIH) guidelines when considering a patient for any type of weight loss surgery including lap band surgery.
The NIH guidelines for obesity surgery:
- Patient's BMI should be 40 or higher (morbidly obese), or
- Patient's BMI is between 35 - 40 with obesity co-morbidities ***
Obesity co-morbidities are other medical conditions that are present in a patient who is obese, such as hypertension, heart disease, diabetes, or sleep apnea.
Another general guideline used for qualifying lap band patients is if the person is 100 pounds or more overweight.
*** UPDATE: FDA Lowers BMI Requirements for Lap-Band Surgery
On February 16, 2011, the Food and Drug Administration lowered the Body Mass Index requirements for Lap-Band weight loss surgery to a BMI of 30 (rather than 35) for patients who have at least one related health condition.