Lap Band Insurance

In recent years, insurance companies have slowly begun to cover the costs of weight loss surgery, because many of them realize it can save them money in the long run. While not all insurance companies are inclined to cover your costs, there are ways of convincing your provider that your surgery should be covered and that you meet the needed requirements.

We hope that this document will help you in your attempt to receive coverage from your insurance company. Learn the sixteen tips and questions to ask your insurance provider as well as the eight steps to getting your surgery covered. The following is an outline of the important points and steps to take in order to get the coverage you need for your weight loss surgery.


I. Eight Steps To Meeting The Insurance Requirements.

II. Sixteen Questions To Ask The Insurance Company.

III. About The Insurance Authorization Process.

IV. Seven Participating Insurance Companies.

Aetna Requirements.

Blue Cross Blue Shield Requirements.

Cigna Requirements.

First Health Requirements.

Great West Healthcare Requirements.

One Health Plan Requirements.

Unicare Requirements.

V. Appealing The Insurance Company's Decision..

I. Eight Steps To Meeting The Insurance Requirements

The National Institute of Health's criteria are important to know if you want insurance to cover your weight loss surgery. There are laws in many states that require insurance companies to give you benefits if you meet the NIH criteria. Many times, you should first schedule the initial consultation with your bariatric surgeon, so they can provide you with the information you will need to give your insurance company.

While insurance companies will take a while to give you the information you need and are likely to give you the run around, here are some helpful steps you can take to help the process along and insure that your surgery is covered.

1.    Read and fully understand your insurance company's certificate of coverage, so that you know exactly what should be covered.

2.    Attend a support group meeting to learn from others who have already had the surgery and ask how they received insurance coverage.

3.    Document all personal health information, including:

4.   Height

5.   Weight

6.   BMI (body mass index)

7.   Diet history

9.   Medical problems related to obesity

10.  Copy of your primary physician's medical record to document weight over the last 5 years

11.  Document every obesity-related doctor visit you make, including visits to diet centers, fitness clubs, and weight loss programs.

12.  Obtain a letter from your primary physician stating the need for weight loss surgery.

13.  After your initial bariatric doctor consultation, get an obesity surgery referral from the bariatric doctor as well. It is crucial to have all of your physicians' support.

14.  Make sure you keep all receipts and accurate records of your expenses relating to doctors visits and weight loss attempts.

15.  Call your insurance company to find out if weight loss surgery is covered, which types are approved and if you can choose your own surgeon. (If this is not explained in your certificate of coverage.)

16.  Also, know the codes that the insurance companies use for weight loss surgery. The ICD-9 Diagnostic Code for Morbid Obesity is 278.01.

17.  The CPT Procedure Code for LAP-BAND surgery is 43770 and is refers to a "gastric restrictive procedure, without gastric bypass, for morbid obesity." Another code is 43644, which refers to a "gastric restrictive procedure with gastric bypass and Roux-en-Y." Use this for a gastric bypass surgery.

II. Sixteen Questions To Ask The Insurance Company

It is important to keep a detailed record of every time you speak with your insurance company about weight loss surgery. Write down their answers to your questions along with the person's name and the exact number, including the extension, you called.

When you speak with a customer service representative form your insurance company, here are some important questions to ask:

1.    Is surgery for morbid obesity covered with my current insurance plan?

2.    If not, is there a different plan I can obtain to be covered for weight loss surgery?

3.    What CPT procedure codes are covered and is LAP-BAND surgery (CPT code 43770) covered?

4.    Can I receive a copy of the policy on the surgical treatment of morbid obesity? (ICD-9 Code 278.01)

5.    What specific information do you require before authorizing the surgery?

a.    A nutritional consult?

b.    A psychological consult?

c.    Medical clearance from a physician?

d.    Note form a surgeon?

e.    Documentation of past weight loss attempts?

f.     Documentation of the length of obesity?

g.    Documentation of any health problems related to obesity?

h.    Medical records from the past five years?

6.    Is it required to see an in-plan provider for the LAP-BAND or gastric bypass surgery?

III. About The Insurance Authorization Process

In order to get the insurance company to authorize your surgery, your bariatric surgeon must send a letter to your primary care physician in order to verify the "medical necessity" of your surgery. Listed below are the main factors to consider when a doctor classifies a patient as obese.

1.    Your BMI (body mass index) is 40 or high, classifying you as morbidly obese.

2.    You have been morbidly obese for at least five years prior to surgery

3.    For the past two years, you have attempted other methods of weight loss at the advice of your doctor, such as diets and exercise.

4.    You have another pressing medical condition, such as hypertension, diabetes, sleep apnea, degenerative arthritis, and heart disease. These can constitute medical necessity for obesity surgery.

Please remember to mention any other major health conditions to your physician and bariatric doctor, including psychiatric or emotional problems. Also mention if you have:

.      Significant liver, kidney, or gastrointestinal disease

.      A history of alcohol or substance abuse

IV. Seven Participating Insurance Companies

Listed below are some insurance companies that are known to either partially or completely cover bariatric surgery procedures. This is however not a guarantee, each patient's case is uniquely evaluated by their insurance provider. Additionally, the requirements we have listed below may not cover all requirements needed in your specific case. It is important to consult with your insurance provider about all specific requirements.

.      Aetna

.      Blue Cross Blue Shield (in some states)

.      Cigna

.      First Health

.      Great West Healthcare

.      One Health

.      Unicare

.      Humana**

.      United Healthcare**

.      Oxford Health Plan**

.   

**Limited information available about these providers, please consult the insurance provider directly.

American Family Insurance**

Aetna Requirements

Aetna will only cover Roux-en-Y gastric bypass in most cases, but will sometimes cover LAP BAND in specific individual cases.

Required Documentation:

.         Presence of morbid obesity that has persisted for at least 5 years, defined as either:

.         Body mass index (BMI)* exceeding 40; or

.         BMI* greater than 35 in conjunction with the following severe co-morbidities that are likely to reduce life expectancy:

.    Coronary heart disease; or

.    Type 2 diabetes mellitus; or

.    Obstructive sleep apnea; or

.    Hypertension (BP> 140 mmHg systolic and /or 90 mmHg diastolic)

NOTE: A PHYSICIAN'S SUMMARY LETTER IS NOT SUFFICIENT DOCUMENTATION

.         Patient has completed growth (18 years of age or documentation of completion of bone growth);

.         Clinical records documenting the medical/dietary therapies (within two years prior to the surgery) by an attending physician who supervised the member's participation.

.    Documentation of five year weight history; AND

.    Documentation of any medication that was prescribed by a physician to assist in weight loss; AND

.    Co-morbidities and cardiac risk factors such as smoking, hypertension, family history, etc.; AND

.    Surgical consult report indicating need for surgery.

.         Documentation of pre-operative evaluation and clearance for members who have a history of severe psychiatric disturbances or who are currently under the care of a psychologist / psychiatrist or who are on psychotropic medications.

Blue Cross Blue Shield Requirements

Required Documentation:

Presence of morbid obesity that has persisted for at least 5 years, defined as either:

.         Body mass index (BMI)* exceeding 40 OR

.         BMI* greater than 35 in conjunction with the following severe co-morbidities that are likely to reduce life expectancy:

.    Coronary heart disease; or

.    Type 2 diabetes mellitus; or

.    Obstructive sleep apnea; or

.    Hypertension (BP> 140 mmHg systolic and /or 90 mmHg diastolic)

.         Clinical records documenting the medical/dietary therapies by an attending physician who supervised the member's participation.

.         History and physical with documented five year history of morbid obesity

.         Documentation of failure of 12 consecutive months' medically supervised non-surgical methods of weight reduction by an MD, DO or nurse practitioner - that includes nutritional, medication or maintenance therapy, behavior modification, exercise or increase of activity

.         Initial evaluation

.         Psych evaluation

.         Documentation of willingness to comply with preoperative and postoperative treatment plans.

Cigna Requirements

Required Documentation:

BMI of 40 or 35 and higher with one or more co-morbidities for at least one year with all of the following criteria:

.         At least 18 years of age and/or full skeletal growth.

.         Documentation of a 26 consecutive week (6 months) professionally supervised weight loss program within the last two years. This could include programs such as Weight Watchers, or a program by a physician.

.         Internal Medical clearance to include a history and physical, height, weight, body frame, blood pressure readings, and lab testing. This can be done through your primary care physician.

.         A consultation from a dietician.

.         A psychological evaluation.

First Health Requirements

Required Documentation:

.         History and Physical from your primary care physician documenting any co-morbid conditions.

.         A psychological evaluation.

Great West Healthcare Requirements

Required Documentation:

.         Presence of morbid obesity with a Body mass index (BMI)* of 40 or greater than 35 with a significant co-morbid condition such as:

.         Life threatening cardiopulmonary disease; or

.         Disabling degenerative joint disease of the lower extremities; or

.         Type 2 diabetes mellitus; or

.         Obesity related pulmonary hypertension

.         Clinically significant asthma; or

.         Obesity related cardiomyopathy; or

.         Moderate to severe gastric esophageal reflux disease; or

.         Uncontrolled hypertension.

.         Minimum age of 18.

.         Weight management history which includes all of the following:

.    A. Obesity duration greater than five years.

.    B. Participation in a weight loss program for six months (within the last two years) with chart notes that include documentation of all of the following:

.  a. Dietary program for weight loss which consists of a very low calorie diet program (i.e. Optifast), Nutri-Systems, Jenny Craig or Weight Watchers which includes monthly weigh-ins and nutritional analysis.

.  b. Monthly clinical encounters with a healthcare professional who does not perform weight loss surgery.

.  c. Increased activity/exercise regimen unless contraindicated.

.  d. Behavior modification program supervised by a qualified professional to reinforce dietary therapy and increased physical activity.

.  e. Weight loss management history includes pharmacotherapy with physician prescribed weight loss drugs or documentation of why pharmacotherapy was not tried.

.         Multidisciplinary pre-operative evaluation that includes all the following:

A. Nutritional evaluation by a licensed nutritionist, dietitian or physician.

B. Medical evaluation that addresses endocrine disorder or other cause of excessive weight gain that might be reversible without surgery

C. Psychological evaluation by a licensed mental healthcare professional that addresses the following:

.    a. Absence of problems related to alcohol or substance abuse for at least one year.

.    b. Absence of major psychotic or disabling mental health diagnosis including mania and schizophrenia.

.    c. Absence of compulsive or obsessive-compulsive disorder.

.    d. Eating disorders (i.e. bulimia)

.    e. Likelihood of willingness to comply with post-op requirements.

.         Commitment to planned post-op multidisciplinary approach that includes on-going regular meetings, at least monthly for first six months post-op, with psychiatric or psychological support/consultation and dietician or nutritionist support/consultation and exercise.

One Health Plan Requirements

Required Documentation:

.         Documentation of being 100 or more pounds overweight for the past 3 years

.         You must be between the ages of 25 to 55

.         A consultation from a dietician

.         A psychological/psychiatric evaluation

.         You must not have had an alcohol habit in the past year

.         You must provide documentation of physician supervised weight loss attempts in the past 3 years

Unicare Requirements

Required Documentation:

.         Internal Medicine clearance (can be obtained through your primary care physician)

.         Thyroid panel to include TSH level (can be obtained through your primary care physician)

.         A psychological/psychiatric evaluation

V. Appealing The Insurance Company's Decision

If you are denied coverage for your obesity surgery, there is still a chance you can receive full or partial coverage by filling for an appeal. It is important to find out the specific reason you were denied by the insurance company before you contest it. Appeal as quickly as possible to have the best chances of getting coverage. You may need to consult with a lawyer or an insurance advocate to insure you are filling the appeal correctly. Appealing can reverse the original decision, but be sure you know how many times you are allowed to appeal, which should be stated on your certificate of coverage.