Lap Band Surgery - Insurance Appeal Letter

Lap-Band InsuranceIf your initial request for lap band surgery is not approved, your insurance company will provide you the opportunity to appeal the decision. The appeals process will allow you to address the specific reasons as to why the insurer denied coverage for lap band surgery and ask them to reconsider the request. While it is discouraging to receive a denial, be aware that this is not the final word. Many individuals have successfully appealed an insurance decision and won insurance coverage for lap band surgery, even though their initial request was denied.

The Denial Letter

First, it will be important to get the denial in writing and fully understand the specific reasons of why the insurance company denied coverage for lap band surgery. Once the specific reasons are known, then you can prepare your basis for appeal.

  • Make sure you know the specific reason(s) for denial of coverage
  • Get it in writing

In some instances, the denial is based on missing documentation or a clerical error, situations which can easily be cleared up by supplying the correct information. More likely, the insurance company denied the request either because it did not find that there was sufficient documentation to prove a medical necessity or that their requirements were not met.

Lap Band Surgery Insurance

Writing the Appeal Letter

Once you have collected the necessary documentation (medical history, weight loss efforts, health conditions, treatments), the next step will be to write a letter to the insurance company to appeal the decision. It is important that all contact with the insurance company is documented and that you keep copies of everything. Find out the appeals procedure - where the letter should be sent, the date it must be filed, and what paperwork needs to be included with the appeals packet.

  • Patient identification - (name, policy number, group number, claim number)
  • Reason for denial - (as listed in denial letter)
  • History of obesity - (weight, health conditions, previous weight loss efforts)
  • Information to correct errors
  • Documentation to support medical necessity of LAP BAND Surgery
  • Purpose of letter - (to request that the insurer reconsider the denial and approve coverage of LAP BAND Surgery)

Insurance Appeals Sample Letter

Although you will need to customize the wording to fit your situation, the following sample letter will help outline the information you should include in your appeal request:

(Date)

(Name of Contact Person at Insurance Company)
(Insurance Company Name)
(Address)
(City, State ZIP)

Re: (Your Name)
(Group Number/Policy Number)
(Case Number/Claim Number)

Dear (Name of Contact Person at Insurance Company),

I am writing this letter to appeal (insurance company name) decision to deny coverage for LAP BAND Surgery. Based on the letter of denial dated (insert date), this procedure was denied because "(quote specific reason for the denial as stated in denial letter)."

To review my health history, I was diagnosed with the following health conditions on the dates stated. I have also listed my previous methods of weight loss attempts and other treatments.

• I have suffered from (health condition) since (date). My treatments for this condition include (list all treatments). (repeat for all health conditions, including obesity, high cholesterol, sleep apnea, high blood pressure, diabetes, and all others).

At this time, my doctor (name of doctor) believes that LAP BAND Surgery is medically necessary and is the appropriate treatment for the above mentioned health conditions. I have also enclosed a letter from my doctor, (doctor's name), that discusses my medical history in more detail.

As you may have based your denial on incorrect or incomplete information, I wanted to provide the following information that shows why I disagree with your denial and why I believe LAP BAND Surgery will significantly benefit my health and should be approved.

• (Provide specific facts to support LAP BAND surgery and counter reasons of denial, including medical studies, medical articles, and other information that shows that procedure resolves and improves your diagnosis).

Based on this information, I am asking that you reconsider the denial and approve coverage for LAP BAND Surgery. My doctor has scheduled surgery for (date). If you need any additional information, please contact me at (telephone number).

Thank you for your time and attention to this matter.

Sincerely,

(Your name)
(Your address)
(Your City, State ZIP)
(Your telephone number)
(Your email address)

The Insurance Requirements for Lap Band Surgery

Most insurance companies will cover lap band surgery IF there is a medical necessity for the procedure and you meet their requirements for coverage approval. It is up to you to prove the medical necessity of the procedure by supplying the necessary documentation and to fulfill the requirements as listed in your policy. The appeals process will provide you the opportunity to supply the necessary documentation to prove your claim and show that you have met their requirements.