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Financial and Insurance Information
The FDA approved the BioEnterics® Lap-Band® on June 5, 2001 (for details Click Here). Since this is a relatively new procedure, insurance reimbursement still seems to be determined on a person-by-person basis as opposed to an insurance-by-insurance basis. Although the following general information is provided for educational purposes. Talk to you Dr. Marsden about your individual case.
Insurance Verification
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.
You may also see if you can get partial coverage for the Lap-Band® System surgery. There may be a way to have some of the tests covered, or perhaps have another (approved) abdominal surgery done simultaneously thereby covering some of the anesthesia and hospital fees.
Below is a partial list of companies that are known to either partially or completely cover Lap-Band® System surgery. Please note that this list should not be construed as a guarantee that you will be covered - it's provided for informational purposes only.
• Blue Cross (in some states)
• Humana
• First Health
• One Health
• Tufts Health Plan
• United Healthcare
• Oxford Health Plan
• Medica
• American Family Insurance
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 more than 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, Patient Financing and Self-Pay
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. Some patients have been very successful in their appeals. Dr. Marsden's office staff can work with you through this process.
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 www.obesitylaw.com.
When insurance reimbursement is not available, patient financing is another alternative you may consider. Please ask about our patient financing programs.
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