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 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!
I just wanted to update you and let you know how much we appreciated your help in getting us this approval. My wife had the procedure done in October and has been doing great. Already she has lost weight and her sugar counts are stable and doing fine. The Doctor has taken her off Insulin and High Blood Pressure medicine as a result. She feels real good on the progress she made so far. Once again, thanks for all your help.
Thank You, so much. I cannot express my gratitude for what you and
Walter do. It is absolutely overwhelming to have someone that has your
back and knows exactly what avenues to take to seek approval. I know
that it is not always successful but, I am so grateful for the outcome.
I spoke with my doctors office yesterday and my surgery is scheduled for
December 12. Merry Christmas to me!
Please give Walter my heart felt, Thank You!
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!
Thank you so much for your email. I honestly didn’t think that things would change with this appeal but it was worth trying. Thank you for all of your hard work and follow up. I cannot tell you how much I appreciate everything that you have done for me. It is amazing to know that there are people in your corner.All the best to you and your clients.
I have done nothing but cry my eyes out for the last 30 minutes!!! I can’t even begin to tell you how grateful we are for the two of you. I have already passed your information on even before this approval came through because I could tell how genuine you are. You’re doing good work. I can’t thank you enough!!! I really think you just helped save my husband’s life, and obviously I want him here with me for as long as I can have him. You two are truly blessings to us. I know your words of encouragement mean a lot to [my husband]. Thank you. Thank you. Thank you.
Oh my goodness!!!! Kelley – I can’t say thank you enough!!!! Thank you, thank you, thank you!!!! This is the BEST news ever. I am SO HAPPY! Thank you! Please tell me where/how I can leave you a review. Both you and Mr. Lindstrom went so above and beyond my highest hopes. I am so incredibly thankful. You guys are the best! Calling now to schedule the surgery!!!
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 so much Kelley (and Walter!). I so appreciate all you have done for me!!!
I’m so excited to finally be able to move on!
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.