Bariatric Insurance Denial Overturned – A Revision Case Study
Patients (like me) who have had a successful outcome with their first weight loss surgery, only to re-gain weight years down the road, are often particularly difficult for providers to get approved for a revision or conversion. We handle a great many of these cases and believe our success in getting insurance coverage is key to people continuing on their road to better health. Here’s a great example.
Our office represented this 55 year old woman seeking a revision from an adjustable gastric band placed in 2004 when her BMI was over 52. She successfully lost well over 100 lbs., getting her BMI into the low 30’s, when she began to regain weight and experience a return of her co-morbid conditions, including sleep apnea. While a precise anatomical problem could not be confirmed despite several different diagnostic tests, she began to experience intolerance to her gastric band and it was decided it needed to be removed and that conversion to a RNY was medically necessary. She did have bariatric surgery coverage under her plan.
Her surgeon sought pre-authorization from CIGNA in early 2012 seeking to remove the gastric band and perform the RNY gastric bypass. CIGNA denied the request on the grounds the treatment was not medically necessary, that there was no “technical failure” of the gastric band and that the patient was not compliant post-operatively. DOES THIS SOUND FAMILIAR BECAUSE IT IS THE SAME SONG & DANCE EVERY INSURANCE COMPANY TRIES TO USE TO DENY REVISIONS, NO MATTER WHAT THE FIRST OR SECOND PROCEDURES ARE – – BLAME THE PATIENT!
The surgeon’s office appealed but really didn’t provide much more information than what was in the pre-authorization request. That’s not unusual – surgeons are great at doing surgery! CIGNA (big surprise) denied that first level appeal but fortunately the patient found out about our office and retained us to assist her through the remainder of the appeals process. We presented a very comprehensive picture of her history, participated in a level 2 appeal hearing with CIGNA to amplify all the reasons why their decision was wrong, and just CIGNA has now overturned the denials of the explant and the RNY conversion and the result is one ECSTATIC PATIENT and a surgeon’s office happy to be able to provide the care believed to be necessary for their patient.
ALL TOO OFTEN PATIENTS AND PROVIDERS BOTH SHY AWAY FROM THE CHALLENGES PRESENTED BY DIFFICULT REVISION AND CONVERSION CASES.
PLEASE ALWAYS KNOW THAT WE CAN HELP! [
I am absolutely over the moon excited right now. I finished my 6 months supervised diet/nutrition with my surgeon’s office back in April, but I was denied when it was submitted to insurance, despite having a BMI of 42 and GERD (they denied it and said GERD wasn’t one of their approved co-morbidities, and my insurance plan requires a co-morbidity regardless of BMI). I immediately contacted Lindstrom Obesity Advocacy and began the appeals process with them. Within a month of them sending in my (wonderfully written) appeal letter, I just received a call to let me know that United has approved me for surgery and has provided their office with the approval and authorization number. . . . I am beyond excited! This is actually happening!!
Hello Walter and Kelley,
I wanted to send a huge THANK YOU to you both, as well as to your team! Everything happened very quickly after my appeal hearing on June 26th, and I had my bypass surgery on July 10th !! And I went back to work on Monday July 15th, so its all been a whirlwind! I am feeling great, the weight is coming off, and I am starting to really feel like I am getting back to normal (well my new normal that is).
This would not have happened without your help, and I am forever grateful for all the work you all did to help me. I will certainly recommend you all to anyone going through the same struggle as I did. You all are just wonderful and made the process very easy. I just want you all to know how much I appreciate all your help!
After my initial denial by Cigna I hired Lindstrom Obesity Advocacy to handle my appeals and am happy to say that my denials were overturned on independent review. Kelley was wonderful, always available to me and always on top of the appeals at every turn. She kept me informed of any progress as soon as it developed. She really seems to care about her clients. I highly recommend using them. My first denial was in June and the denials were overturned in August on independent review. My surgeon’s office commented on how fast the process was compared to the experience of others in their office. . . . It was the best money I ever spent and I am over the moon that this worked out for me. My recommendation is don’t wait to contact them. I contacted them immediately after I got my first denial and they handled the rest. So that’s my two cents!
Dear Walter and Kelley: Today is the 1-year anniversary of my lap-band surgery. To date, I have lost 67 pounds and I am in the best shape of my life – I don’t remember a time that I weighed as little as I do now, not even in high school. The time you spent appealing my case was invaluable and absolutely life-changing for me, and I just want to let you know how very much I appreciate all the work you put into it on my behalf. I am thankful beyond words! God bless you!
Thank you very much for your quick reply and the helpful tips on what should be done. I will proceed as you recommended and contact you again should I need additional assistance. I appreciate knowing that there is someone out there that is willing to fight to help me have a better life. You need to know how much just just the words in your email mean to me. Thanks again and have a wonderful new year!wing that there is someone out there that is willing to fight to help me have a better life. You need to know how much just just the words in your email mean to me. Thanks again and have a wonderful new year!
Didn't Have To Retain Us!
OMG! I was NOT expecting this! I tried to call you when I received your message, but I think your office was already closed for the day. I will call back tomorrow just to say THANKS in person! Looks like Christmas came early! I will contact the doctor’s office tomorrow to schedule the surgery as quickly as possible…Words cannot express how thankful I am for your help! You have been such a pleasure to work with! I will make sure my surgeon and his office staff know how helpful you have been so they can be sure to recommend you to others that might be struggling with the same problem.
You are the best Thanks again for everything you did. I know for sure I never could have accomplished this on my own!
Walter and Kelley,
1 year ago today I had surgery with Dr. Alok Gandhi at Rochester general hospital. I am happy to report that I have lost 120 lbs., off all of my medicine and cpap machine. I take vitamin supplements but everything else is gone. I just wanted to thank you again for your help with CIGNA and wish you both a great day and a very heartfelt “Thank You”.
I had to go to external review but I’m now APPROVED for revision from Band to RNY!!!! I can’t say enough positive things about Kelley & Walter at Lindstrom Obesity Advocacy. If you find yourself stuck with denials from insurance companies, I highly recommend them!
This made my life. Literally. I cannot begin to thank you enough for your expert help in having this over turned for me. I know without your help, it wouldnt have been possible. My surgeon has me scheduled for surgery on Feb 6. I will be sure to stay in touch and let you know how it all goes. I have a lot of hope that I will be able to come off of my insulin pump and have better control with just a few injections. I truly believe this is possible for me, and that my quality of life will be so much better. The work you have done is going to change so much for me. I plan, in turn, to make a difference for many others. Its a pretty great ripple effect, isnt it?
Thank you so much Walter and Kelley ! I don’t know either of you, but I love you both so much! You have truly changed my life and I know that a day will not go by where I will not think of you. I am finally looking forward to my wedding day and it’s because of you two. Can’t wait to share wedding pics 🙂 Thank you a million times over.