To determine if your insurance policy covers obesity (or “bariatric”) surgery, refer to the policy package that all insured people receive after they have paid their first premium, or if they have chosen a plan offered by their 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 the company tells the insured which treatments they have to pay for themselves. You should refer to your insurance information to determine whether your policy covers surgical therapy for the treatment of morbid obesity.
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.
A Letter of Medical Necessity and weight-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.
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.
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.
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