Hello Folks! I'm abenefits person for my company, a big part of my job is explaining our insurance....

The first and most important thing to realize about ANY insurance is that EACH EMPLOYER dictates what their insurance covers.

For instance I have Blue Cross, and I had NO PROBLEM getting covered... even though BLUE CROSS IS FAMOUS FOR DENYING IT.. but that is because my EMPLOYER told them to cover it....

The best way to find out if YOUR COMPANY allows your insurance to cover it is to call the customer service number on the back of your card and see if GASTRIC BANDING (procedure code 43770) is covered. OR you can ask what OBESITY benefits if any that your policy covers.

Another way, is to go ask your Human Resources person if its covered OR ask for a copy of your Medical SPD (PLAN DOCUMENT)The plan document is most likely a book of boring stuff that you got at orientation that you never read this is available in your HR department if your insurance is "Self Insured".

The best advice I could give anyone is to educate yourself about YOUR particular insurance, know how it works.. because the kind people who staff doctors offices won't KNOW the particulars of YOUR insurance since EACH and EVERY Employer has different requirements...........

GOOD LUCK

INSURANCE APPROVAL GUIDE


Malley Surgical Weight Loss Center will assist you in obtaining an approval from your insurance company for the LAP-Band System, but your participation in this often lengthy process is essential. Here are some of the steps you will need to take:

•Review your insurance policy:
It is very important to understand your policy and what is covered. Some insurance policies will have weight loss surgery coverage, but not for the LapBand. In your handbook, look under the “Exclusion of Coverage” section to make sure that surgery for weight loss is not a listed exclusion. For example, a common problem we have found is that both our patients and office staff have been misquoted over the phone by the insurance company regarding the patient’s Bariatric benefits. If weight loss surgery is listed as exclusion, your next option is to pursue the Lap Band surgery as a self pay patient.

•Criteria:
Most insurance companies have criteria that you must meet before they will consider this medically necessary and approve you for surgery. You need to check with your insurance company about what the criteria is. Again, to make sure that you are told correctly, ask if you can obtain a copy of the criteria in writing or get a website that you can print the criteria off of. If you have a document from the insurance company listing the criteria, it will eliminate being misquoted by the insurance representative. Examples of common criteria that is needed are: proof of comorbities (see below), recommendations from Primary Care Physicians (see details below), nutrition evaluation, psychiatric evaluation, proof of attempted weight loss (see details below), 6 month physician supervised diets (most insurance companies are very particular about what they want for these diets and we have had very few patients that have meet this criteria prior to wanting to be approved for the Lap Band. This is usually something that has to be done now and will usually delay your surgery until this is obtained.)



•Retrieve documentation that show “medical necessity” for having the LAP-BAND System procedure:
Get copies of your medical records from your primary care physician and any other healthcare professionals who have treated your obesity and its related medical conditions (such as type 2 diabetes, high blood pressure, sleep apnea, asthma, joint problems, etc.)

•Ask your primary care physician for a letter of recommendation:
This letter should include: your height, weight, and body mass index (BMI) history, any health problems you may have that is related to your obesity and the medications or treatments you are receiving for these conditions.

•Retrieve receipts/records that show your history of attempts to lose weight:
If you have gone to commercial weight loss centers such as Jenny Craig or Weight Watchers®, find your receipts or contact the centers and request copies of your records.

•Be Patient:
After our office has sent your predetermination letter to the insurance company, it could take anywhere from 30-45 business days before a response is received.