Insurance Information

More and more insurance policies are covering weight-loss surgery, due to a growing recognition by the healthcare industry of the high costs associated with excess weight and weight-related health problems. However, navigating the insurance process can sometimes be overwhelming.

That is why at DayOne Health, we have dedicated insurance specialists on staff to help you manage the insurance approval process and understand all of your available options. If you are seeking insurance coverage, we will make every effort to work with you to maximize your benefits under your existing insurance plan.
The following explains a list of the steps involved in the insurance approval process. The more you learn about the process in advance and the more information you can provide up front, the faster your request will be processed and the greater chance you’ll have of a successful outcome.

If you have any additional questions about coverage, please contact our Insurance Coordinator.

AVAILABILITY OF INSURANCE COVERAGE
FOR PATIENTS WITH A BODY MASS INDEX BELOW 35

Patients with a BMI above 30 may qualify for weight-loss surgery coverage through their insurance provider, but need to have at least one diagnosed weight-related health problem. At the time of your surgical consultation, our insurance coordinator will review the steps for insurance verification and obtaining approval from your insurance company, if applicable.

Unfortunately, patients with a BMI below 30 won’t qualify for insurance coverage of at this time. However, DayOne Health offers a self-pay option for patients without insurance coverage or who do not meet their insurance criteria. We also partner with several companies that can provide affordable financing for weight-loss surgery patients.

INSURANCE APPROVAL PROCESS

Please review the following steps carefully. While the insurance approval process may seem overwhelming at first, carefully following each step, keeping yourself informed on the issues, and documenting everything will make the process easier.

STEP 1: CALL YOUR INSURANCE COMPANY

The first step in obtaining insurance coverage for your weight-loss procedure is to contact your insurance company directly to find out if they cover the surgery. Before you begin, it is important for you to know your height, weight, BMI, diet history, and any weight-related medical problems you may have. Have all this information ready when you call. Call the Customer or Member Services line listed on your insurance card and ask the following question:

Is weight loss/obesity surgery (or “bariatric surgery”) a covered benefit?

If the answer is “yes,” then ask:
Is the LAP-BAND® (or adjustable gastric banding) procedure approved? (CPT Code #43770)

Is the vertical sleeve gastrectomy (or gastric sleeve) procedure approved? (CPT Code# 43775)

Be sure to write down
1. the date you called, 2. the name of the person you spoke with, and 3. their extension.

Not covered? Be persistent!If your insurance company tells you that bariatric surgery is not covered, you may need an attorney to help you prove the medical necessity of the procedure.

A great resource for bariatric insurance assistance is Lindstrom Obesity Advocacy. The founder of the site, Walter Lindstrom, is a bariatric surgery patient dedicated to providing insurance advice for obese patients. The website offers many helpful articles on how to get your insurance company to approve your procedure.

Can you select whatever surgeon you want?
Important: You may also want to request a copy of their policy on the surgical treatment of morbid obesity. Be sure to write down (1. the date you called, 2. the name of the person you spoke with, and
3. their extension.)

Not covered? Be persistent!

If your insurance company tells you that bariatric surgery is not covered, you may need an attorney to help you prove the medical necessity of the procedure.

A great resource for bariatric insurance assistance is Lindstrom Obesity Advocacy. The founder of the site, Walter Lindstrom, is a bariatric surgery patient dedicated to providing insurance advice for obese patients. The website offers many helpful articles on how to get your insurance company to approve your procedure.

Covered? – Proceed to Step 2

If you find out the procedure is covered, proceed to Step 2, following the steps according to your insurance coverage type:

A. PPO Coverage or B. HMO Coverage

STEP 2: SUBMIT REQUEST FOR APPROVAL

A. PPO Coverage
During your initial consultation at DayOne Health, your surgeon will complete a Physician Evaluation. This evaluation is then sent to your insurance provider along with a Request for Pre-Authorization for coverage. Generally, your insurance company will take anywhere from 4 to 6 weeks to respond to this request.While you are waiting for a response, we recommend that you follow-up directly with your insurance company by calling the Member Services number on your insurance card. When you call, indicate that you are checking on the status of your Pre-Determination Request. They will need your member ID number listed on your card to access the information. Be sure to document who you spoke with during each call.

Once you have received an Approval Letter from your insurance company, congratulations! You can proceed with scheduling your surgery. Call us at 312-2551-1900 to schedule your surgery appointment.If coverage is denied, you have the option to appeal your insurance company's decision. See “Step 3: The Appeal Process" below for more information.



B. HMO Coverage
If you belong to an HMO, you will need to obtain a referral from your primary care physician (PCP) before scheduling your initial consultation at DayOne Health. Then, you will receive a Physician Evaluation by our surgeon during your initial consultation visit.

The Physician Evaluation and a Referral Request for pre-operative testing and surgery will be submitted to your PCP or medical group. We recommend that you follow-up on the Referral Request by contacting your PCP or medical group indicated on your insurance card and asking about the status of the request. Be sure to document who you spoke with during each call.

If you receive a Referral for Surgery, congratulations! You can proceed with scheduling your surgery. Call us at 312-239-3838 to schedule your surgery appointment.

If benefits are denied, you have the option to appeal the decision. See "Step 3: The Appeal Process" below for more information.

STEP 3: THE APPEAL PROCESS

In the event that your request for insurance coverage is denied, you have the option to appeal the denial of coverage. Appeals can be processed either by DayOne or by the individual patient. If you need to submit an appeal, be sure to do so in a timely manner. Typically, insurance companies require that patients submit an appeal within 30-60 days after receiving a denial of coverage notice.

The appeal should include information that disputes the insurance company’s reasoning for denial of coverage (for example: medical journal articles, copy of patient’s insurance policy, etc.).

The following websites are dedicated to helping patients with insurance authorization issues and are terrific resources for patients with insurance concerns:

✔ Lindstrom Obesity Advocacy: This site is dedicated to helping obese patients navigate the insurance process and other weight-related legal problems.
✔ Obesity Help
✔ Patient Advocate Foundation

Please feel free to contact DayOne with any questions or concerns you may have — our insurance specialists are here to help!


Important LAP-BAND® System Safety Information

Indications: The LAP-BAND® System is indicated for weight reduction for patients with obesity, with a Body Mass Index (BMI) of at least 40 kg/m2 or a BMI of at least 30 kg/m2with one or more obesity-related co-morbid conditions. It is indicated for use only in adult patients who have failed more conservative weight reduction alternatives, such as supervised diet, exercise and behavior modification programs. Patients who elect to have this surgery must make the commitment to accept significant changes in their eating habits for the rest of their lives.

Contraindications: The LAP-BAND® System is not recommended for non-adult patients, patients with conditions that may make them poor surgical candidates or increase the risk of poor results (e.g., inflammatory or cardiopulmonary diseases, GI conditions, symptoms or family history of autoimmune disease, cirrhosis), who are unwilling or unable to comply with the required dietary restrictions, who have alcohol or drug addictions, or who currently are or may be pregnant.

Warnings: The LAP-BAND® System is a long-term implant. Explant and replacement surgery may be required. Patients who become pregnant or severely ill, or who require more extensive nutrition may require deflation of their bands. Anti-inflammatory agents, such as aspirin, should be used with caution and may contribute to an increased risk of band erosion.

Adverse Events: Placement of the LAP-BAND® System is major surgery and, as with any surgery, death can occur. Possible complications include the risks associated with the medications and methods used during surgery, the risks associated with any surgical procedure, and the patient’s ability to tolerate a foreign object implanted in the body. Band slippage, erosion and deflation, reflux, obstruction of the stomach, dilation of the esophagus, infection, or nausea and vomiting may occur. Reoperation may be required. Rapid weight loss may result in complications that may require additional surgery. Deflation of the band may alleviate excessively rapid weight loss or esophageal dilation.

Important: For full safety information please click here, talk with your doctor, or call Apollo Customer Support at 1-855-551-3123


CAUTION: Rx only.