Insurance Criteria

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.

Submission Requirements

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 more)
• 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. Please contact our office for additional information.

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 website at 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—-or view our patient financing information online.