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"If I ever was having a lap-band, I would take the plunge with with Dr. Clinch. I really liked him."
Sue - from, \"Is Weight Loss Surgery Right for You?\" seminar
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Back to Bariatric Home
Affordability
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 your surgeon about your individual case.
Even if your insurance doesn’t cover the cost of surgery, it may cover some preoperative testing such as
a chest x-ray or echocardiogram, or the cost of counseling or psychological therapy.
Insurance Verification
To determine if your insurance policy covers obesity (or "bariatric") surgery, refer to your insurance
policy package.
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." There are several criteria to meet for example, physician documented diet for 6 months to 5 years depending on your insurance. If this surgery is a
covered benefit when medically necessary, then it should be covered when patients meet national and/or
specific plan guidelines of care for morbid obesity.
Below is a partial list of companies that are known to either partially or completely cover bariatric
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.
Submission Requirements
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
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. Our 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.
If you self-pay, you may want to discuss with your insurance company if this will affect your insurance
payments in the future. In general, insurance policy may cover emergency removal of the band and may
cover post-op medications such as prescription antacids.
We have had patients finance their costs through their own means (e.g., retirement plan, flexible
spending accounts, credit card, cash) and also research other patient specific financing companies
to assist in the up-front cost.
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