The benefits of LAP-BAND® sound incredible. You are extremely interested in the possibilities this procedure could hold for your health and your future, but there is one unanswered question standing in your way: Will your insurance help cover the cost of LAP-BAND® surgery?
For many individuals, LAP-BAND® is covered under their insurance policies. Because weight loss procedures like LAP-BAND® and gastric bypass have become so popular in recent years, most major policies will address the topic in their contracts.
At Lap Band Rockies, we do not work with insurance in our office. However, we can offer you some tips to see if their insurance covers the surgery. When you connect with your health insurance representative, you can ask the following questions to get the coverage information you need.
1. Is weight loss surgery an exclusion on my plan?
 If the answer is yes they will know that they have to pay out-of-pocket for the surgery.
2. Is pre-authorization required for CPT code 43770 for outpatient surgery?
If the insurance company says no then ask the next question below. This question is where many people get confused. Insurance companies may tell you that no pre-auth is required for that CPT code but they don’t tell you if there is a pre-determination phase. That’s where the insurance catch is. I know it happened to me.
3. Is there a pre-determination phase?
If so get a copy of the criteria and see if you can meet the criteria. If you do not meet the criteria then you know that your only other option is to pay out-of-pocket. A lot of the time we get these patients back even if it’s several months later.
Guidelines regarding weight loss procedures like LAP-BAND® should be detailed in your Explanation of Benefits. Check in both the “Covered” and “Not Covered” sections to find an answer. If there is coverage available, there may be stipulations, for instance a condition of obesity must be proven, or the procedure must be deemed “medically necessary” by your primary care physician or LAP-BAND® surgeon. In some cases, insurance providers will offer partial coverage, considering the procedure both a health improvement and a cosmetic enhancement.
In general, many providers will use the candidacy requirements set forth by the National Institutes of Health which states that weight loss surgery may be medically necessary for people who have a body mass index of 40 or greater, or have a BMI of at least 35 with co-morbidities like diabetes and hypertension. An insurance company may require you to provide proof that previous weight loss attempts have been unsuccessful.
You may need to have signed document from your physician explaining why LAP-BAND® is medically necessary. In the case of coverage denial, there may be an opportunity to appeal and try again for authorization. If you discover that insurance coverage for LAP-BAND® is not feasible, you always have the option of obtaining third-party financing in order to delay payment.
Find out if LAP-BAND® is covered under your current insurance policy. Then contact Dr. Gerald Kirshenbaum  at Lap Band Rockies today to set up a personal consultation and speak with one of our coordinators about your benefits and payment options.Â
