Appeals and Patient Financing
The FDA approved the LAP-BAND® System on June 5, 2001 (for details go to
To determine if your insurance policy covers obesity (or "bariatric")
surgery, refer to the insurance policy package that you have received after
paying your first premium or provided through a plan offered by your employer.
Typically, there are two sections that describe the extent and limits of
coverage. The first is usually called "What Is Covered" or
"Covered Expenses." These are the healthcare benefits for which the
company will pay. The other section is "What Is Not Covered" or
"When the Plan Does Not Pay Benefits." In this section, look for any
statement that the company excludes coverage for weight control, for the
treatment of obesity, for the surgery for weight control, or for the
complications of the surgery for weight control. Some policies will outright
exclude bariatric surgeries. Others may have certain parameters around which
bariatric procedures they cover and how much of the costs they cover. Look for
statements such as, "Surgery for the treatment of obesity is covered when
deemed medically necessary," or "Surgery for the treatment of obesity
is (specifically) excluded except when medically necessary." If this
surgery is a covered benefit when medically necessary, then it should be
covered when patients meet national guidelines for care for morbid obesity.
Below is the list of companies that are known to either partially or completely
cover LAP-BAND® System surgery in Southern California. Please note that this
list in no way insures that you will be covered -- it's provided for
informational purposes only.
A Letter of Medical Necessity and weigh-loss history are necessary to obtain
prior authorization for obesity surgery. A Letter of Medical Necessity states
why significant weight loss is medically necessary for a patient and usually
includes the following information:
Patient's weight (which should be 100 pounds or more above ideal weight or a
BMI more than 40 or at least 35 with associated medical problems to qualify)
List of medical problems associated with obesity, such as type 2 diabetes,
sleep apnea, hypertension, etc.
Number of years patient has been overweight (which should be at least five or
Number and types of failed weight-loss programs attempted in the past
If you create a document or packet listing all your weight-loss attempts
(self-controlled or medically supervised) and their results, you can
substantially increase your chances of getting insurance coverage for the
LAP-BAND® procedure. You should include any commercial diets or medical records
of your weight-loss efforts.
Appeals and Patient Financing
If coverage has been denied upon the initial prior authorization request, you
can appeal by addressing the specific reasons why your request has been denied.
You can also contact a lawyer with expertise to help you with the appeal. More
information about legal help can be found at The Obesity Law and Advocacy Web
site at http://www.obesitylaw.com.
When insurance reimbursement is not available, patient financing is another
alternative you may consider. Please ask us about available patient financing
programs during the patient seminar or your office visit.