Approval for bypass but not Lap Band

Has anyone gotten insurance approval for the bypass but not lap band? If so, what were the reasons and were you able to fight it? My surgeon recommended lapband because I'm young and it's a safer procedure. Any suggestions?

Ben: Though all insurance companies are not made equally, most of them do follow the same payor guidelines to ensure patient safety and cost containment. The general mentality around the refusal to pay for lap band and the insistence on more "traditional" gastric bypass is due to the perceived investigational nature of lap band. Because gastric bypass has more of a track record with providers, insurance companies are more at ease in allowing patients to seek this type of surgery. So, from a safety perspective, the insurance company feels that gastric bypass is more viable (whether or not this thinking is correct is moot). The insurance company also looks at the procedures from a cost-containment basis. The perception that a patient has to continually visit his or her provider for adjustment of the band presents itself as costly, as the provider making the adjustments can bill for various procedures rendered during the office visit. Basically, after the surgery, it can cost more to maintain a lap band patient than someone going for the Roux-en-Y. Insurance companies are simply not willing to absorb the costs--at least, not at this time. Perhaps, in time, the insurance company will have the data needed to make a more informed decision on whether to allow a patient different choices in weight-loss surgery. I hope I was able to provide you with information and rationale that can assist you in your goal for weight-loss surgery.

Thanks for the help! In fact, I received the denial letter. It said that because I have a BMI of over 50, the lap band is considered experimental.  I asked the insurance coordinator at the surgeon's office and she believed that if I got my BMI to 50, they might approve it.  But then I run the risk of the insurance companying saying, "well if you lost that weight, you can lose more".  Because I'm only 24, I'm concerned about the irreversibility of a gastric bypass.  Any thoughts? If it's the bypass or nothing, I lean towards the bypass but I just don't know.

It's the potential "bang-for-your-buck" thing.  I have BC CA and they do not approve for LapBand for BMI's in excess of 50 because they quote studies which support the idea that there is not evidence that higher BMI patients--ON AVERAGE--lose enough weight to become NON-MO. 

For example, a 350 pound person should (according to the charts) weigh 132-175.  Let's use 150 because it's easy.  So that person has to lose 200 pounds to get to a normal BMI.  If he/she loses 50% of his/her excess weight--100 pounds--his/her BMI will be 35.9, which-- with comorbidities--would make that person STILL ELIGIBLE for wls. A 5'10" 400 pound person who loses 50% of his/her excess weight would have a BMI of 43.  The higher the pre-op BMI, the less likely--they say--it is that banding will bring that person to the range of normal BMI. So, as a thinking person, you ask, "Well, is that not similar to the RnY excess weight loss stats after a few years?" Indeed it is.  With a hitch.   If you take a crowd of RnY patients and LapBand patients and chart their weight losses for a few years, what you find is that most of those RnY patients who are at 50% a few years out lost more than 50% of excess weight and then regained some...taking them to the 50-60%-range, but that most banded patients who are at 50% three years out never did lose any more than that. So they end up at the same place, but because the RnY takes more people down to a lower weight, the insurance company can claim that the surgery was a success...and the patient later screwed up. Sue

Thanks Sue! That explanation really helped. I also have BC of CA. It makes sense (in some weird insurance logic way).  Right now I'm waiting to hear back from the surgeon as to whether we should proceed with a bypass.

I'd be willing to try losing weight to get my BMI down to 50, but then I have this fear that the insurance company will just deny anyway.

Who is your insurance with?  Also go to their web site and get the requirements and they should tell you what it takes to get approved.  For the longest time Aetna would not approve lap band so I sat on the sideline and did nothing except checking their web site every few months for changes.  Then in March they changed it and I am in the process of getting everything in line for them according to their guidelines.  The best advise get their guidelines for approval and follow them.  If you get denied then you have great ground for approval.  But if your insurance company does not cover it for any reason email your insurance company, even talk to the people in you HR department. 

 

If there is anything I can do PM me.

I was told when i was trying to get approved for surgery that Lap Band was harder to get approved for than RNY because it is reversible and some insurance companies still consider it experimental.

I finally heard back from the insurance administrator at the surgeon's office. She spoke with my surgeon and he said that I would also be a candidate for the RNY.  So she sent all my paperwork back to the insurance for approval. After looking at their written policy on bariatric surgery, I can see nothing that could serve as a reason for denial. Although I wanted the lapband, I've decided that I can be happy with the RNY.  Keep your fingers crossed for me, I'm hoping to hear back soon.