1. Insurance Options
2. Cash Options
3. FAQS About Insurance

Congratulations on taking the first step to a more healthy and active life. Getting approval from your insurance company can be very frustrating and this letter is designed to help you understand the approval process and give you a head start in collecting the documentation required by your insurance company. Your insurance benefits are decided by your employer as they select the specific benefits they want to provide their employees. The insurance company decides on what documentation (i.e. medical records) they require to determine medical necessity (unless the employer has specifically requested this approval process be waived). Please understand that, if predetermination of benefits is required, they will not accept anything less than their published requirements.

The Insurance Coordinator works closely with each insurance company and has been well educated on what each company requires. You can contact your Member Services representative for a list of their requirements, or you can access your benefits information online and print a copy of it from there. First step to get started is to, call your insurance company and ask specifically: “Do I have out of network benefits for the surgical treatment of morbid obesity with the adjustable gastric lap band (CPT code 43770)?” Do I need a referral from my Primary Care Physician?” Make sure you write down the date, time, and name of the person you spoke with. Ask them to document your complete conversation at the beginning, in their system for future reference.

All insurance companies do require some or all of the following, with the exception of most United HealthCare plans.

* Your latest Complete History and Physical and a Letter of Medical Necessity by your Primary Care Physician. Some insurance companies require these from Dr. Jayaseelan also. Some Primary Care Physicians do not recognize this procedure as a benefit to their patients. IF you need a letter of medical necessity and your PCP will not provide you with one, we have an Internal Medicine doctor at out office that does recognize the many benefits of the surgery and will be more than happy to meet with you for a thorough History and Physical and then will also write a letter of medical necessity to Dr. Jayaseelan.

* A Psychological Evaluation to show your insurance company that you are mentally capable to handle all the changes you will need to make with the band. This evaluation needs to address any psychological conditions you have had in the past.

* A Nutritional Evaluation to show your insurance company that you are fully aware of the diet changes you will be required to make and that you can follow along with an exercise plan.

* Detailed weight loss history ranging from 3-12 consecutive months with 1 physician that documented your weight at each visit, an exercise plan that was followed daily, calorie intake instructions, and any prescription drug therapy given in your chart. The “chief complaint” for each visit mush show “weight loss” and include detailed notes by the physician regarding a diet plan that specifically states caloric intake, foods to avoid and foods to include, an exercise and behavior modification program documented how it was followed daily at each visit. As far as records go, we do not need records that do not pertain to weight loss, i.e., pap smears, x-ray’s, any visit to the doctor for any reason other than weight loss unless your insurance company requires documentation to show a history of obesity over several years, and treatment for any co-morbidities.

* Documentation showing a history of morbid obesity for a period of 2 to 5 years. This can come from annual exams from a gynecologist for women and yearly physicals for men. If you have regular visits with any physician that documents your weight in the chart, those records will work.

We will give you a list of exactly what your insurance company requires at your first appointment and you will be responsible for getting that information to our office. Once we receive all of your records, a Pre-determination letter will be generated to be sent along with the records. WE usually send everything by fax unless the insurance company requests they be mailed, ant then it is certified. Insurance companies require all documentation be submitted at one time.

As we receive your medical records, we will go though them and document that each item needed is in your chart. We will send you a copy of the chart list showing what we have received and what we still need so you can continue to have the necessary records sent. Once everything has been received by our office it will be sent to your insurance company. After they receive it, it can take from 4 to 8 weeks to get a response back. It is always possible that your insurance member services number 3-4 weeks after your records have been sent to check on the status of your request. Unfortunately, due to the large volume of patients, it is not possible for our office to check the status. If we are notified by mail we will check your chart for labs and EKG, and contact you to schedule if approved. If you are not approved, you will receive a letter in the mail from your insurance company. We will then be able to choose a course of action for a possible appeal.

Not all insurance companies offer coverage for this surgery. We do have published medical journal articles that will be utilized for appeals for coverage, but it does not always work. Also keep in mind, insurance companies sometimes give us the incorrect information when we verify your benefits, so it is a great idea to keep a record of who you talk to and the date and time you spoke with them, no matter what the reason for your call is. We keep this same information in your chart, from all of our calls in case we have any problems with them for any reason.

Once an approval has been received, there must be current lab work and a current EKG or other cardiac testing no more than 3 months prior to the actual surgery date. This is a requirement by the surgery facility. The labs needed prior to surgery are a CBC, CMP, LIPID, and TSH. These can be obtained through your Primary Care doctor, or this office can supply you with a lab slip for the blood work and the name of a physician that does the EKG/STRESS ECHO for us. Please keep in mind that these tests are required for your safety during surgery.

When you have been approved your chart will be given the surgery scheduler. All questions should be directed to Veronica V. at our main number to verify surgery dates and to check on receipt of lab work and testing reports required for surgery. Surgery will be scheduled along with a pre-operative appointment. You will be seen by Dr. Jayaseelan for a pre-operative history. You will then see our Surgery Scheduler for your pre-op and diet instructions, scheduling your 2 week post-operative visit, and at that time your payment for your deductible and/or coinsurance will be collected in full for Dr. Jayaseelan’s services.

If you are financing your surgery through one of the credit companies, we will have the loan documents for you to sign at your pre-operative visit. We will then fax your signed form to the finance company in order for the funds to be disbursed to each facility.



If you do not have insurance or you do not have benefits for this type of surgery there are cash options available.

The cash out-of-pocket cost for the Lap-Band procedure is $12,500. This amount covers Dr. Jayaseelan’s fee, the surgery center fee, the anesthesiologist fee, and one (1) year of adjustments to your band.

If you wish to finance this procedure or any other form of payment, the cost is also $12,500. This amount covers all of the same fees as listed above. The following companies finance this type of procedure:

Does my insurance cover the Adjustable Gastric Lap Band?
The best way to determine the answer to that question is to contact Member Services. The number is always listed on your insurance card. Ask them:

Do I have out of network benefits for surgical treatment of morbid obesity?
The Insurance Coordinator verifies benefits after your initial consultation to obtain information on your benefits, deductibles and how much is met. It usually takes two to three weeks for this process due to the large volume of patients.

What do I have to do to get approved?
Every insurance company has a list of medical records they must review prior to making the decision to approve your surgery. They use these records to determine medical necessity. Ask your customer service representative for a copy of these requirements or you can find them on their website. These records will come from your prior visits with any and all of your doctors, new visits with a nutritionist and a psychiatrist. The insurance companies are attempting to see that you can stick to a diet plan and that you are in the best possible health for surgery.

How is the information gathered and submitted?
After your initial consultation with Dr. Jayaseelan, you will be given a list of what your insurance company requires. It is your responsibility to get this information to the Insurance Coordinator. A list of requirements will be placed in your chart and as each item comes in it will be checked off. When all items are checked off, a letter of pre-determination will be written and the entire package of records will be sent to your insurance company either by fax or by certified mail.

How long does it take to get approved?
Most insurance companies take 30 to 60 days to go through the approval process. Typically they will send a letter to the office and to the patient informing them of their decision. We contact you as soon as we hear from your insurance company. We request that you start calling your insurance company approximately 3 weeks after we submit everything to check the status of our request. This office can not call to check the status due to the number of patients we have waiting to get approved. The insurance companies typically respond to their members much better than they do the providers.

How much will this cost me?
While you are on the phone with Member Services, ask them what your “out of network” deductible is. This is the only amount Dr. Jayaseelan’s office will collect from you for your surgery. This amount will be collected at your pre- operative visit with Dr. Jayaseelan.

Is that all I will have to pay?
Dr. Jayaseelan’s office does not balance bill patients for the Adjustable Gastric Lap Band. However, after surgery you may receive bills from the surgery center and the anesthesiologist. They will be an out of network provider also, but they will calculate your portion of their charges using your “in network” benefits. We can not give you any information regarding the surgery center or the anesthesiologist charges. They are a separate entity from Dr. Jayaseelan and we do not have access to that information.

How do I qualify for this surgery?
The general rule of insurance companies is that your BMI must be 35 or greater with additional co-morbidities such as, Hypertension, Sleep Apnea, Coronary Heart Disease, Type II Diabetes, and Dislipidemia; or your BMI must be 40 or greater without any co-morbidity.