• Will My Insurance Cover the LAP-BAND^® System Procedure?
• Insurance Authorization Requirements
• The LAP-BAND^®
  REIMBURSEMENT SOLUTIONS Hotline
• Appeals
• Insurance Alternatives
• LAPBAND^® System Patient Financing Program

If you're going to pursue LAP-BAND^® System weight loss surgery, there are a number of options for you to pay for the procedure. Insurance and financing may seem complicated, but here (and on the page Costs of Surgery) is some crucial information that can help you make the best financial decision. Please be sure you check with your LAP-BAND^® System surgeon to confirm what options are available to you.

Click on the icon to view a PDF file of the medical expense tax deductions brochure

Insurance and Payment Options

Video Transcript

Will My Insurance Cover the LAP-BAND^® System Procedure?

• LAP-BAND^® Adjustable Gastric Banding System surgery was approved by the Food and Drug Administration (FDA) on June 5, 2001, (for details, go to http://www.fda.gov/cdrh/mda/docs/p000008.pdf)
• To find out if your policy covers weight loss (or bariatric) surgery, refer to the policy package that you received after paying your first premium, or that was provided by your employer.
• If you don't have a copy of your health benefits, contact the Human Resources department of the employer which provides your coverage.
• Typically, there are two sections that outline the extent and limits of your coverage. Look for "What is Covered" or "Covered Expenses". These are the expenses that the insurance company will pay.
• The other sections to check are "What is Not Covered" or "When the Plan Does Not Cover Benefits".
• Look for any reference to exclusion of coverage for weight control, for the treatment of obesity, for surgical weight control, or for the complications of weight control or weight control surgery.
• Some policies will not cover any bariatric surgery. Other plans may have restrictions about which surgeries and what they will 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."
• If the surgery is covered when medically necessary, then you will be covered if you meet national guidelines for the care of morbid obesity.
• You may also get partial coverage - this can include: tests, or by having another approved abdominal surgery done at the same time, thereby covering some of the hospital and anesthetic fees.

Below is a partial list of insurance companies that are known to either partially or fully cover LAP-BAND^® System surgery. Please note that this list is not a guarantee that you will be covered - this is for informational purposes only.

• Aetna
• American Family Insurance
• Blue Cross (in many states)
• Cigna First Health
• Health Net
• Humana
• One Health
• United Healthcare

In addition to the list provided, on February 21, 2006, the Centers for Medicare and Medicaid Services (CMS) published a National Coverage Determination for bariatric surgery. They determined that they would cover the LAP-BAND^® System procedure, along with Gastric Bypass and Biliopancreatic Diversion (BPD). Any Medicare beneficiary, including those over the age of 65, is covered for surgery as long as he/she meets the normal criteria for surgery. However, please note that the Medicare beneficiary's procedure of choice must be performed at either an American Society for Bariatric and Metabolic Surgery (ASMBS) accredited Center for Excellence or and American College of Surgeons (ACS) Level I Bariatric Surgery Program. If your facility is not accredited by either of these bodies, payment for the procedure may not be made by Medicare. Check with your surgeon's office before you schedule any procedure.

Insurance Authorization Requirements

It's routine that you will probably require prior authorization from your insurance company for weight loss surgery. You will likely need to send a "Letter of Medical Necessity" and personal weight loss history stating why significant weight loss is medically critical for you. This letter usually includes:

• Your weight (should be at least 100 pounds overweight; a BMI of at least 40; or a BMI of 35+ with a weight-related medical condition. Click here to check your BMI.
• A list of serious medical conditions associated with obesity such as Type 2 diabetes, sleep apnea, hypertension, or any other condition from which you suffer.
• The number of years that you have been overweight (which should be at least five years).
• The number and type of failed weight loss programs you have tried in the past.

A good way to significantly improve your chances of being approved for LAP-BAND^® System weight loss surgery insurance is to create a document or package listing all your previous weight loss attempts (on your own or with medical supervision) and the results. You should include any commercial diets that you've been on, as well as your medical records that document your weight loss efforts.

Click on the icon for a sample Letter of Medical Necessity.

The LAP-BAND^® REIMBURSEMENT SOLUTIONS Hotline

The Allergan LAP-BAND^® REIMBURSEMENT SOLUTIONS Hotline is dedicated to helping you with the insurance verification process as you prepare to undergo the LAP-BAND^® System procedure. Our experienced LAP-BAND^® REIMBURSEMENT SOLUTIONS Hotline counselors can take you through the time-consuming reimbursement process, providing:

• Personalized assistance
• In-depth knowledge of insurance policies specific to your geographic area
• Faster turnaround time to process benefits requests
• Accurate, up-to-date information about insurance and payment options

We're here with the timely and personalized support you need

• Insurance Benefits Verification - Will verify coverage status for the LAP-BAND® System by your payer.
• Prior Authorization (PA) Support - Help you research PA requirements for specific payers, assist you and your surgeon’s practice in submitting all the necessary paperwork, and follow your case until a decision is made.
• Patient Financing Options - CareCredit^® is a financing program that can help remove the economic barrier for the LAP-BAND® System procedure if you do not have other reimbursement. Please go to the The LAP-BAND^® System Patient Financing Program section for more details.

The LAP-BAND^® REIMBURSEMENT SOLUTIONS Hotline can help you reduce the time you spend arranging reimbursement, freeing you to focus on the next steps in your weight loss journey with the LAP-BAND^® System.

Appeals

If your request for prior authorization for the LAP-BAND^® System surgery is denied by your insurance company, you may have the opportunity for a limited number of appeals of this decision. The process varies according to the plan, so be sure to check your insurance company's specific appeal policy. Generally, you can appeal if your denial is based on the following reasons:

• The LAP-BAND^® System is investigational
• The LAP-BAND^® System is experimental
• The insurance company has no previous knowledge of the LAP-BAND^® System
• You did not meet the criteria for the surgery.

An effective appeal should:

• Answer the specific reason(s) for the denial
• Include supporting documentation

You can also contact an experienced lawyer 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

Click on the icon to view a PDF file of the appeals brochure.

Insurance Alternatives

There are circumstances where health plans will not cover the LAP-BAND^® System surgery, regardless of your medical necessity. In this situation, patients often feel they have exhausted their options. This is not the case. There are other financing options you may want to consider.

• Out of Pocket Payment - depending on your personal financial situation, you may want to consider a lump sum payment.
• Patient Financing
  • Loans - there are special medical financing companies that you may contact. They offer easy access and a full range of payment plans.
  • The LAP-BAND^® System Patient Financing Program

The LAP-BAND^® System Patient Financing Program

Your doctor may also be a participant in the LAP-BAND^® System Patient Finance Program -- a program that links LAP-BAND^® System patients with CareCredit^®, a GE Money company. If not, your doctor can easily enroll in this program by contacting his or her LAP-BAND® System Account Manager.

What is CareCredit^®?

CareCredit^® is the nation’s leading patient financing program. It has helped over 6 million patients worldwide get the treatment they need. It provides a choice of convenient, monthly payment plans designed to help patients pay for healthcare expenses not covered by insurance. This includes co-payments, deductibles, and elective treatment.

How much will they cover?

Upon request and approval, CareCredit^® can cover medical fees ranging from $1,000 to $25,000.

How do the payment plans work?

With CareCredit^®, patients can choose from two types of payment plans:

• Low-Interest Payment Plans – Receive an 11.9% APR and low minimum monthly payments. Available with 24, 36, 48, or 60-month plans.
• No-Interest Payment Plans – Receive a 0% APR and pay no interest as long as you pay the minimum monthly payment on time every month and the balance is paid in full by the end of 3, 6, 12, or 18 months.

How do I apply for CareCredit^®?

To apply, visit www.carecredit.com or call 1-800-677-0718. You will receive a decision immediately.

You should weigh the advantages and disadvantages of each of these options and carefully make the decision that is best for you. If you still have questions regarding these options you should seek advice from a financial professional.

Cyndi's Story

"The best investment I ever made." Cyndi, LAP-BAND^® System patient since 2003

"I paid for my LAP-BAND^® System surgery myself. I'm glad I did. I was 291 pounds, and I felt that my young son deserved to have an active, healthy mother. I chose the LAP-BAND^® System because it can be adjusted to fit my specific needs. I've lost 115 pounds, and I can enjoy an active life with my son. The LAP-BAND^® System was a wonderful investment - for myself and my family.

Your results may vary. Click here for detailed risk information.