Insurance Issues & Financing

At Life Shape, we are committed to help you negotiate the complex process of obtaining insurance approval for your weight loss surgery.

Insurance Verification
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 received the policy package 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. For instance, Medicaid, and Tricare do not pay for the LAP-BAND®

Medicare has indicated that they will pay for LAP-BAND® surgery, but only at a limitted number of centers. At this point, we are not able to bill Medicare for LAP-BAND® surgery.

Below is a partial list of companies that cover LAP-BAND® System surgery in Florida. To date, no company has paid the total cost of the program so all patients will have some amount of out of pocket expense.

First Health - Mail Handlers
United
United Harris Corporation
Aetna (only for patients that are thought to be to high risk for gastric bypass)
Cigna
A small number of Blue Cross policies. (Not Blue Cross of Florida - check your policies)

Submission Requirements
A Letter of Medical Necessity and weigh-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. Contact us and we can assist you in preparing these documents.

Appeals
If weight loss surgery is specifically excluded from your insurance contract (see above) then there is little recourse other than changing insurance companies. This is a very risky maneuver because there is no guarantee that your new insurance company will cover your surgery. If weight loss surgery is not excluded by contract, but initial authorization is denied then each company has an appeals processes that can be initiated. There are a limited number of appeals, however, so this process should be undertaken with care. We recommend you consider enlisting the assistance of an attorney for your appeals. We recommend The Obesity Law & Advocacy Center.

The Obesity Law & Advocacy Center is a full-service private law firm devoted to representing morbidly obese persons in a variety of legal matters. The firm handles all types of civil litigation with an emphasis in appeal and grievance proceedings challenging the denial of medically necessary treatment for obesity and morbid obesity. They can be reached at www.obesitylaw.com

Patient Financing
When insurance reimbursement is not available, patient financing is another alternative you may consider. Since we are an outpatient based program, and the cost of surgery at an outpatient center is considerably less than surgery at a hospital, we can offer LAP-BAND® surgery for considerably less than many other programs. In many cases the cost of LAP-BAND® sugery in our program is half of what is typically charged for the gastric bypass procedure. Individual costs vary depending on your specific needs. Please contact our Financial Specialist Kathy Blair for assistance with self funding and financing.