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!
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.
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!
Thank you. I’m so emotional right now! You guys are helping me change my life. When everyone told me that I would not be approved,you guys made me feel confident that there was a way. I am forever grateful.
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!
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 want to almost cry after seeing what you have done and going to the ends of the earth in defending my efforts and struggles. I want to thank you so much (the both of you) for all of your efforts. It has really meant the world to me.
Oh my God!
Thank You so much! It has been wonderful working with 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 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!
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!