Denied – Fought – Won!


B.B. was like many patients we help. She had very successful weight loss with an adjustable gastric band placed in 2010 but in 2013 she began suffering problems such as vomiting, reflux, swallowing (known as “dysphagia”) and nausea. She couldn’t tolerate solid food, her fantastic weight loss stopped and she started gaining back what she lost. She was devastated. She worked with her surgeon’s office, first on her diet and then she had her band totally deflated. Nothing helped. She suffered for months and continued to gain weight. It turns out she suffered a “slip” of her band, a known complication which can occur and which was confirmed by diagnostic testing. She had benefits for bariatric surgery. Her doctor wanted to remove the band and convert her to a sleeve gastrectomy either at the same time or down the road in a separate procedure. Reasonable treatment plan, right? So what happened?

Well first, removal of the band was denied altogether because she was “non-compliant” with her post-op treatment. The records did not show documented exercise, behavior modification and dietary changes. Naturally the conversion to a sleeve was also denied.

Yup! The rocket scientists for the insurer apparently thought her slip didn’t need to be repaired because she did it to herself so her conversion was not considered medically necessary! Of course they didn’t care about her daily suffering, her weight going up and her comorbidities coming back. They didn’t even seem to care about what horrible things might happen if the symptoms of her band slipping got more severe.

How could they have reached this conclusion? Never underestimate the incompetence that insurance companies are capable of showing. One of the key benefits patients have when we get involved with cases is we make sure we understand HOW the denial decision was made, WHAT documentation the decision was based upon, and WHO made the decision. Quite often it becomes clear the insurer’s process is so flawed that the patient never had a chance at getting pre-authorized in the first place and appealing on her own or through the surgeon’s office would not necessarily gotten the information that we obtain. Going through those steps can be time-consuming battle but ultimately this can be the difference whether or not a patient gets surgery approved.After we got the documentation relied upon to make that decision in advance of filing her first appeal, the level of incompetence was clear: MORE THAN HALF OF “HER” CHART INCLUDED RECORDS FROM A DIFFERENT PATIENT! THEY DIDN’T EVEN REALIZE THEY WERE REVIEWING THE WRONG PERSON’S CASE WHEN THEY ISSUED THE DENIAL! A lot of blame probably rests on them having the case reviewed by a “peer specialist” who made the initial decision to deny. That “peer” was a retired surgeon who never performed a gastric band surgery, sleeve gastrectomy or any type of revisional bariatric procedure! Clearly he did not have the background to know that a slip of her band WAS NOT AND COULD NOT BE HER FAULT!

Happily we can report we were successful getting B.B. approved for both removal of her band and conversion to sleeve gastrectomy. But it always makes us wonder how many patients are out there who did not fight a decision that was reached based on bad documentation by an unqualified person. That’s why we always want you to fight for the treatment you need. YOU DESERVE IT!

601-C East Palomar Street #480 Chula Vista, California 91911 Tel - 877-992-7732 Fax - 844-384-9199

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