Insurance for Lap Band Surgery
How to Speed Up the Insurance Approval Process
The amount of time it takes to get an answer back from your insurance carrier varies between companies and patients. While some patients may hear back within a couple of weeks, for some it can take three or four weeks or even longer. Since getting approval can be a drawn out process, you should submit your request to the insurance company as soon as possible.
To help speed up the process, it is helpful for you as the patient to follow-up with the insurance company and work pro-actively on your own behalf. About one week after your submission packet is sent in, call the insurance company and ask about the status of your request. Then continue to follow-up on a regular basis and persist until you get an answer and approval. Your lap band provider should also be willing to assist you with your approval request and follow-up with the insurance company as well.
How to Help With the Insurance Approval Process
To help with the insurance approval process, it is important for you to gather up all the documentation that will help convince the insurance company that lap band surgery is a medical necessity. Supportive documentation includes all diet records, medical records, medical tests, records for medically supervised diet attempts, receipts for exercise equipment or gym memberships, and other documentation that shows your attempts at weight loss over the years.
It is also important to provide your insurance company with a letter from your primary care physician stating that you have struggled with obesity and weight loss over the years, have not been able to lose weight under medical supervision, have obesity related co-morbidities, and that weight loss surgery is a medical necessity. If you can get letters from several medical doctors and consultants stating the same findings, it will help establish a medical necessity for lap band surgery.
Most lap band providers have an insurance coordinator to help you submit a successful request. Once you have submitted your paperwork to the insurance company, stay in touch with the insurance company and follow-up on a regular basis.
Handling Insurance Denials for Lap Band Surgery
While it can be discouraging to have your insurance company deny your first request for lap band surgery, don't give up. There is still hope, if you are willing to fight the decision with your insurance company. Many patients have had their insurance pay for the surgery even when they didn't expect it. If you get denied, appeal.
When you receive a denial for lap band surgery, contact the insurance company and find out the specific reasons for denial. Often, the first denial is based on factors which can be worked out, such as lack of appropriate medical information and weight loss documentation.
Your best ally should be your physician, who can help you present your case to the insurance company by providing medical documentation of previous visits for weight loss attempts and writing a letter confirming the medical necessity of lap band surgery and stating any co-morbidities you have due to obesity.
Keep pressing the insurance company to review your case and continue to work on meeting their requirements. It may take some time, involve making quite a few phone calls and sending many pages of documentation, but hopefully all the aggravation will lead to approval for the lap band surgery. There have been many lap band patients who were successful with their appeals.
If you and your doctor are not able to convince the insurance company with your efforts, you may try contacting the Obesity Law and Advocacy Center (www.obesitylaw.com) for legal advice.
How to Appeal Insurance Denials for Lack of Medical Necessity
Insurance requests for lap band surgery are often denied because the insurance company cites a lack of medical necessity. Insurance companies will consider a procedure a medical necessity when it is needed to treat a serious or life-threatening medical condition and there are no other effective or alternative treatments. While lap band surgery is used to treat morbid obesity, the insurance company considers other methods of treatment to be available, such as dieting, exercise, medications, and behavior modification.
The insurance company needs evidence that supports the claim of medical necessity. Medical necessity denials are usually due to a lack of documentation, such as medical records for one to five years of physician supervised dieting, psychiatric evaluation, or a letter from your physician stating your obesity co-morbidities, showing that you have made serious efforts to lose weight by other methods and have not been able to do so.
How to Appeal Insurance Plan Exclusions for Weight Loss Surgery
Even if your insurance plan has an exclusion for weight loss surgery and coverage for lap band surgery is denied, it may still be possible to appeal. While the exclusion often specifies "obesity surgery" or "treatment of obesity," the appeal would be based on your doctor's or surgeon's recommendation that lap band surgery is the best method of treating your life-threatening obesity-related health condition. These conditions, such as diabetes, high blood pressure, or heart disease, are usually covered conditions.
Tips for the Appeals Process
- Ask for assistance: Talk to your doctor and bariatric surgeon and ask for their help with the appeal. They should be somewhat familiar with the approval and appeal process and willing to provide advice as how to best handle the insurance requirements.
- Seek legal advice: You may also want to seek advice from an organization that specializes in obesity advocacy, such as Obesity Law and Advocacy (obesitylaw.com), for help with your insurance appeal.
- Keep records: Document all contact and phone calls with the insurance company, including date, who you talked to, and details of conversation.
- Keep copies: Make copies of everything you receive from or send to the insurance company, including letters and medical history.
- Get it in writing: If the insurance company makes any promises, ask for written confirmation of the conversation.
- Proof of receipt: Send all correspondence to the insurance company via certified mail with return receipt, which provides written confirmation of mailing and receipt.
- Be your own best advocate and don’t give up!: Don’t expect the insurance company to make it easy on you, it may be a long and drawn out process, but have hope that your persistence may pay off with approval for lap band surgery.
- Keep it professional: In your dealings with the insurance company, try to remain pleasant and polite, yet firm and persistent. Although you may be frustrated and upset, it is not productive to take it out on the person on the phone or to write a nasty letter. Keep it professional and keep in mind what you are trying to accomplish - approval for lap band surgery.
Patient Cost for Lap Band Surgery with Insurance
Even if your lap band surgery is covered by insurance, you may still be responsible for paying any co-pay, deductible, or co-insurance amounts. This amount will vary between companies and health plans, and applies to group plans, individual policies, and Medicare/Medicaid coverage. You will need to check with your insurance company in reference to your specific plan as to the limits on your health plan policy.