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!
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!!!
Thank you so much for all your hard work. I don’t have words to express my gratitude for all you and Kelley have done for me! I agree I felt as though the case might be doomed! So excited to move forward! Again, I am beyond thankful for all you have done!
Thank you so very much for this wonderful letter of request. I honestly regret not contacting you when I was initially denied. I am just flabbergasted at the detail and the evidence based references provided. WOW!!! I deeply regret not knowing you existed. You really take the WORD advocacy to a whole new MEANING. Words cannot describe how satisfied I am to see such documentation and how thankful I am for your help. Thank you!
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!
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!
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.
I WAS APPPPPPPPPPROVED!!!!!!!! The IRO overturned the denial!!!!!!!!!!!!!!!!!!!! I just got home from work and there was a letter. I’m a big baby right now over this. I’m going to run out of tissues, lol. I will forward you this letter first thing in the morning and will call your office as well! I can not thank you ALL enough. WOW!!!!
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.
Thank you so much Kelley (and Walter!). I so appreciate all you have done for me!!!