Insurance Denials for Lap Band Surgery

I posted this a few months ago, and I think it’s worth a repeat. The Northwest Weight Loss Surgery site has a link to one of the best pages ever - Obesity Law And Advocacy Center. Attorney Walter Lindstrom is founder, and his firm focuses on issues of concern to obese people. Now, as I said before, if you’re reading this page, you don’t plan on being obese for long, so what is the relevance?

Well, Mr. Lindstrom has a lot of advice on what you need to do to get your insurance to cover your lap band procedure. For starters, a lot of insurance companies mandate that you establish that you were on a supervised diet program and require that you provide them with notes. He has an entire paper on the importance of doing this. His basic point is that for many of us, getting insurance approval isn’t that quick anyway. Most doctors want you to lose 10 pounds or so before surgery to make the liver smaller anyway, so Mr. Lindstrom says “do it”. It will get you a little farther down the road while you work through the insurance issues, and will make you healthier for the surgery.

There are lots of articles and FAQ page as well. There were two questions that particularly caught my eye and I think will be relevant to many of you.

I’VE BEEN DENIED OBESITY SURGERY BY MY INSURANCE COMPANY BECAUSE CLAIM IT ISN’T MEDICALLY NECESSARY. CAN YOU HELP ME?

We are fortunate to be able to help most anyone in this position and have a success rate overturning denials based on “medical necessity” or failure to meet criteria for surgery that is in excess of 90%. We can be most effective if we get the case or claim right at the time of the first denial. If you wish to inquire about us advocating for you in that type of case, click here.

Oooo la la! A success rate of over 90%! That’s what I want to hear!!!!!

And then this:

MY INSURANCE COMPANY DENIED ME BASED ON A LACK OF DOCUMENTATION OF WEIGHT LOSS EFFORTS AND I DON’T HAVE ALOT OF THAT INFORMATION….CAN YOU HELP ME?

This is one of the areas we spend a great deal of time and have had very good success. While it is very, very important for patients to go back to their various medical providers to get whatever historical records are available, the fact is many people don’t have or cannot locate such records. That should not stop anyone from seeking surgery. First, you can always postpone the surgery until you comply with your company’s requirements, whether they are 6 months, 12 months, 18 months or more. However, we also understand that many of you have “been there, done that” and don’t want to wait anymore. We work successfully on a great many of those cases despite a client not having a great deal of documentation and we would urge you to give us a chance if this is the basis for denial you confront.

This was something I was wondering about. I live on a diet. I don’t think there are that many changes I could make to my diet that would allow me to lose weight. But after reading this site, tomorrow I’m going to be figuring out ways to get on a supervised diet, just in case I wind up with insurance coverage and use it for my surgery.

And in case you need help but you’re thinking you can’t afford Mr. Lindstrom, he says this:

ISN’T HIRING AN ADVOCATE GOING TO BE VERY EXPENSIVE?

Fear of professional fees are unfortunately one of the primary reasons why many Americans, in our opinion, are denied access to health care they require. Many people cannot afford costly fees and many attorneys and other types of advocates charge fees which are greater than the costs of the treatment being denied. Obviously, in that case, it would make no sense to hire such a person or firm.

Our office has worked very hard to make high quality services affordable to anyone who needs them. We have kept our overhead extremely low and have streamlined our file handling to maximize results for our clients. We’ll discuss our various fee options with you on an individual basis, but our current structure starts under $500, depending on what you require.

While it is important that this office charge and collect a fair fee for the work that we do, we have never allowed someone’s ability to pay fees to be the final deciding factor as to whether or not we can help them. We don’t want anyone to not contact us simply based on an erroneous assumption that hiring us is too expensive. We will work hard, if necessary, to create a payment plan which meets your personal situation.

And since most of you don’t live in California:

I DON’T LIVE IN CALIFORNIA - - - CAN YOU STILL HELP ME?

The answer to this question is generally “Yes,” but circumstances will differ from case to case. First of all, you must understand that you are retaining our services as a designated authorized “representative” to assist you with your appeal; we are not acting as an “attorney” on your behalf. In those instances, it is generally not necessary for us to be admitted to the bar for your state.

If we take on the matter as attorneys (rather than as lay advocates), we do have to be admitted to practice in the jurisdiction for that case. In those instances, we associate local counsel to assist with following the local rules and to sponsor our admission to that state’s bar for purposes of that particular case. That is called being admitted pro hac vice (for purposes of that case).

There are a few things to keep in mind. If you want us to help you with your appeal, you’re not going to be obligated to file any type of lawsuit or arbitration or other type of litigated solution to the dispute. You’re also never obligated to keep us as your attorneys if you wish to file such an action; in fact, we too retain the right to not move forward with a litigated case and, in some instances, we may be unable to take on that representation because we may be witnesses to the payer’s conduct.

So. yes, he might very well be able to help you even if you live out of state.

There is a lot of great stuff to read there, so I’d encourage you to spend some time at his site. He has an entire paper on getting your insurance carrier to approve you. I’m going to read that tomorrow and report back as well.

The Northwest Weight Loss Surgery site has a link to one of the best pages ever - Obesity Law And Advocacy Center. Attorney Walter Lindstrom is founder, and he is specializing in laws and discrimination that impact the obese. Now, if you’re reading this page, you’re not planning on being obese for long so you may wonder how this impacts you!

Well, Mr. Lindstrom has a lot of advice on what you need to do to get your insurance to cover your lap band procedure. For starters, a lot of insurance companies mandate that you establish that you were on a supervised diet program and require that you provide them with notes. He has an entire paper on the importance of doing this. His basic point is that for many of us, getting insurance approval isn’t that quick anyway. Most doctors want you to lose 10 pounds or so before surgery to make the liver smaller anyway, so Mr. Lindstrom says “do it”. It will get you a little farther down the road while you work through the insurance issues, and will make you healthier for the surgery.

There are lots of articles and FAQ page as well. There were two questions that particularly caught my eye and I think will be relevant to many of you.

I’VE BEEN DENIED OBESITY SURGERY BY MY INSURANCE COMPANY BECAUSE CLAIM IT ISN’T MEDICALLY NECESSARY. CAN YOU HELP ME?

We are fortunate to be able to help most anyone in this position and have a success rate overturning denials based on “medical necessity” or failure to meet criteria for surgery that is in excess of 90%. We can be most effective if we get the case or claim right at the time of the first denial. If you wish to inquire about us advocating for you in that type of case, click here.

Oooo la la! A success rate of over 90%! That’s what I want to hear!!!!!

And then this:

MY INSURANCE COMPANY DENIED ME BASED ON A LACK OF DOCUMENTATION OF WEIGHT LOSS EFFORTS AND I DON’T HAVE ALOT OF THAT INFORMATION….CAN YOU HELP ME?

This is one of the areas we spend a great deal of time and have had very good success. While it is very, very important for patients to go back to their various medical providers to get whatever historical records are available, the fact is many people don’t have or cannot locate such records. That should not stop anyone from seeking surgery. First, you can always postpone the surgery until you comply with your company’s requirements, whether they are 6 months, 12 months, 18 months or more. However, we also understand that many of you have “been there, done that” and don’t want to wait anymore. We work successfully on a great many of those cases despite a client not having a great deal of documentation and we would urge you to give us a chance if this is the basis for denial you confront.

This was something I was wondering about. I live on a diet. I don’t think there are that many changes I could make to my diet that would allow me to lose weight. But after reading this site, tomorrow I’m going to be figuring out ways to get on a supervised diet, just in case I wind up with insurance coverage and use it for my surgery.

And in case you need help but you’re thinking you can’t afford Mr. Lindstrom, he says this:

ISN’T HIRING AN ADVOCATE GOING TO BE VERY EXPENSIVE?

Fear of professional fees are unfortunately one of the primary reasons why many Americans, in our opinion, are denied access to health care they require. Many people cannot afford costly fees and many attorneys and other types of advocates charge fees which are greater than the costs of the treatment being denied. Obviously, in that case, it would make no sense to hire such a person or firm.

Our office has worked very hard to make high quality services affordable to anyone who needs them. We have kept our overhead extremely low and have streamlined our file handling to maximize results for our clients. We’ll discuss our various fee options with you on an individual basis, but our current structure starts under $500, depending on what you require.

While it is important that this office charge and collect a fair fee for the work that we do, we have never allowed someone’s ability to pay fees to be the final deciding factor as to whether or not we can help them. We don’t want anyone to not contact us simply based on an erroneous assumption that hiring us is too expensive. We will work hard, if necessary, to create a payment plan which meets your personal situation.

And since most of you don’t live in California:

I DON’T LIVE IN CALIFORNIA - - - CAN YOU STILL HELP ME?

The answer to this question is generally “Yes,” but circumstances will differ from case to case. First of all, you must understand that you are retaining our services as a designated authorized “representative” to assist you with your appeal; we are not acting as an “attorney” on your behalf. In those instances, it is generally not necessary for us to be admitted to the bar for your state.

If we take on the matter as attorneys (rather than as lay advocates), we do have to be admitted to practice in the jurisdiction for that case. In those instances, we associate local counsel to assist with following the local rules and to sponsor our admission to that state’s bar for purposes of that particular case. That is called being admitted pro hac vice (for purposes of that case).

There are a few things to keep in mind. If you want us to help you with your appeal, you’re not going to be obligated to file any type of lawsuit or arbitration or other type of litigated solution to the dispute. You’re also never obligated to keep us as your attorneys if you wish to file such an action; in fact, we too retain the right to not move forward with a litigated case and, in some instances, we may be unable to take on that representation because we may be witnesses to the payer’s conduct.

So. yes, he might very well be able to help you even if you live out of state.

There is a lot of great stuff to read there, so I’d encourage you to spend some time at his site. He has an entire paper on getting your insurance carrier to approve you. I’m going to read that tomorrow and report back as well.

How To Talk To Your Insurance Carrier About Lap Band Surgery And What To Do If They Say No!

Speaking of the Northwest Weight Loss Surgical Center in Everett, Washington (just half an hour from Seattle), I wanted to post the link to their insurance page which has tons of really good information about how to proceed with your insurance carrier.

Step 1 - Contact Your Insurance Carrier

Call the benefits coordinator at your human resource office and/or call the customer service line listed on your insurance card. State “I am inquiring about my policy benefits regarding the surgical treatment of morbid obesity. Is surgery for morbid obesity a covered benefit?”

If the answer is “no,” you may need an attorney to help you prove that it is medically necessary. We recommend you contact the Obesity Law and Advocacy Center (obesitylaw.com).

If the answer is “yes,” then ask what CPT procedure codes are covered and if this includes LAP-BAND surgery (CPT 43770).

Finally, ask them to send you a copy of their policy on the surgical treatment of morbid obesity (ICD 9 code 278.01).

You may use the list below to help you ask all the questions and to document the answers received.

Telephone number and extension called: _____________________

Is surgery for morbid obesity a covered benefit? Yes No

Which CPT codes are covered?
43770 LAP-BAND Yes No

Do you have a policy on surgery for morbid obesity that I can obtain?

What information do you require before authorizing the surgery?

a. Nutrition consult required? Yes No
b. Psychological consult required? Yes No
c. Medical clearance from your physician Yes No
d. Note from Surgeon Yes No
e. Documentation of weight loss attempts Yes No
f. Documentation of length of obesity Yes No

Ask whether you are required to see an in-plan provider for the LAP-BAND surgery or if you can be treated by a contracted provider such as Northwest Weight Loss Surgery Center. If your insurance plan requires an in-plan provider, and you want to use a contracted provider for your surgery, you may need to consult an attorney.

Get the full name and direct telephone extension of the person with whom you spoke.

The whole page is that informative. If you’re getting ready to call your insurer, take the time to really absorb what’s on this page. They also encourage you to read Walter Lindstrom’s article on preparing to deal with your insurance company - Maximizing Your Chances Of Getting Insurance Approval.

And lastly, as Mr. Lindstrom observes, if your insurer rejects your claim, call the Obesity Law and Action Center, because that’s when they have the best shot at overturning the denial. Right now, they have a success rate of 90% and work hard at making their services affordable for working class people.

Insurance Denial For Lap Bands

I know a lot of you are looking for information on how to deal with denials for lap band coverage by your insurance company. If you’re in that position, I want to encourage you to talk to Walter Lindstrom over at the Obesity Law and Advocacy Center. He says the best time for his law firm to get involved is at the time of the first denial. He says they have over a 90% success rate in appealing denials and that they work hard at being affordable. As I’ve been going through my phone calls, I can tell you that I’ve talked to numerous people in the bariatric surgery industry who have very positive things to say about his work.

I have two separate posts under the category “Appealing Insurance Declines” that I would encourage you to read. One is a link to Mr. Lindstrom’s website, and one is a link to a woman’s letter appealing her carrier’s denial for surgery and spelling out her case, in very forceful language, for coverage.

It’s important to be aggressive on this front, because weight loss surgery is going to make a huge difference in your life. As the study I pointed out the other day noted, people who have lap band procedures have a 72% decline in the risk of death. Just think how happy that will make your mother or your kids.

2007 DEC 3 - (NewsRx.com) — Severely obese people who received the LAP-BAND Adjustable Gastric Banding System to lose weight had a 72 percent reduction in their risk of dying compared to obese people who were not offered any specific weight-losstreatment, according to findings published in the December issue of the Annals of Surgery. The LAP-BAND System was approved in June 2001 by the U.S. Food & Drug Administration for weight reduction in severely obese adults.

And how do we know this?

The study involved two groups of people who were between 37 and 70 years of age with a Body Mass Index (BMI) of 35 or greater: A LAP-BAND System group, which included 966 patients (average age 47, average BMI 45 ) and a previously established population-based cohort of 2119 people who were not offered any specific weight-loss treatment (average age 55, average BMI). There were four deaths (heart disease, cancer(2) and suicide) in the LAP-BAND System group after a median follow-up of four years, vs. 225 deaths after a median follow-up of 12 years in the non-treated group. After statistically controlling for the differences in follow up time, sex, age and BMI, the hazard for death was 72 percent lower for LAP-BAND System patients compared to the non-treated group (hazard ratio for death: 0.28, 95% confidence interval: 0.10-0.85). LAP-BAND System patients lost an average of approximately 63 pounds 2 years after installation.

So, yeah, call Mr. Lindstrom if you’ve received a denial. Don’t just decide you aren’t entitled to surgery. We’re all entitled to be happy and healthy and it may take some work to get there.

Yeeeee-ouch! The Appeal Letter From Hell

I found this letter over at the now-defunct BandLandia.com while surfing around looking for more insurance standards. It’s to the right of the butterflies on the right side of the screen. Keep moving your bottom shuttle right.

I started to quote it here, but it’s just too long and too dense. She addresses who has turned down her request for surgery and questions their qualifications, she enumerates her attempts at dieting and failing, she explains why surgery is desirable, she discusses her BMI and what that means, how being obese handicaps her, and what the law requires. It’s powerful piece of writing. If you’re in a battle with an insurance company, I’d certainly take a loo.

Fantastic Attorney Page For Insurance Lap Band Denials

The Northwest Weight Loss Surgery site has a link to one of the best pages ever - Obesity Law And Advocacy Center. Attorney Walter Lindstrom is founder, and he is specializing in laws and discrimination that impact the obese. Now, if you’re reading this page, you’re not planning on being obese for long so you may wonder how this impacts you!

Well, Mr. Lindstrom has a lot of advice on what you need to do to get your insurance to cover your lap band procedure. For starters, a lot of insurance companies mandate that you establish that you were on a supervised diet program and require that you provide them with notes. He has an entire paper on the importance of doing this. His basic point is that for many of us, getting insurance approval isn’t that quick anyway. Most doctors want you to lose 10 pounds or so before surgery to make the liver smaller anyway, so Mr. Lindstrom says “do it”. It will get you a little farther down the road while you work through the insurance issues, and will make you healthier for the surgery.

There are lots of articles and FAQ page as well. There were two questions that particularly caught my eye and I think will be relevant to many of you.

I’VE BEEN DENIED OBESITY SURGERY BY MY INSURANCE COMPANY BECAUSE CLAIM IT ISN’T MEDICALLY NECESSARY. CAN YOU HELP ME?

We are fortunate to be able to help most anyone in this position and have a success rate overturning denials based on “medical necessity” or failure to meet criteria for surgery that is in excess of 90%. We can be most effective if we get the case or claim right at the time of the first denial. If you wish to inquire about us advocating for you in that type of case, click here.

Oooo la la! A success rate of over 90%! That’s what I want to hear!!!!!

And then this:

MY INSURANCE COMPANY DENIED ME BASED ON A LACK OF DOCUMENTATION OF WEIGHT LOSS EFFORTS AND I DON’T HAVE ALOT OF THAT INFORMATION….CAN YOU HELP ME?

This is one of the areas we spend a great deal of time and have had very good success. While it is very, very important for patients to go back to their various medical providers to get whatever historical records are available, the fact is many people don’t have or cannot locate such records. That should not stop anyone from seeking surgery. First, you can always postpone the surgery until you comply with your company’s requirements, whether they are 6 months, 12 months, 18 months or more. However, we also understand that many of you have “been there, done that” and don’t want to wait anymore. We work successfully on a great many of those cases despite a client not having a great deal of documentation and we would urge you to give us a chance if this is the basis for denial you confront.

This was something I was wondering about. I live on a diet. I don’t think there are that many changes I could make to my diet that would allow me to lose weight. But after reading this site, tomorrow I’m going to be figuring out ways to get on a supervised diet, just in case I wind up with insurance coverage and use it for my surgery.

And in case you need help but you’re thinking you can’t afford Mr. Lindstrom, he says this:

ISN’T HIRING AN ADVOCATE GOING TO BE VERY EXPENSIVE?

Fear of professional fees are unfortunately one of the primary reasons why many Americans, in our opinion, are denied access to health care they require. Many people cannot afford costly fees and many attorneys and other types of advocates charge fees which are greater than the costs of the treatment being denied. Obviously, in that case, it would make no sense to hire such a person or firm.

Our office has worked very hard to make high quality services affordable to anyone who needs them. We have kept our overhead extremely low and have streamlined our file handling to maximize results for our clients. We’ll discuss our various fee options with you on an individual basis, but our current structure starts under $500, depending on what you require.

While it is important that this office charge and collect a fair fee for the work that we do, we have never allowed someone’s ability to pay fees to be the final deciding factor as to whether or not we can help them. We don’t want anyone to not contact us simply based on an erroneous assumption that hiring us is too expensive. We will work hard, if necessary, to create a payment plan which meets your personal situation.

And since most of you don’t live in California:

I DON’T LIVE IN CALIFORNIA - - - CAN YOU STILL HELP ME?

The answer to this question is generally “Yes,” but circumstances will differ from case to case. First of all, you must understand that you are retaining our services as a designated authorized “representative” to assist you with your appeal; we are not acting as an “attorney” on your behalf. In those instances, it is generally not necessary for us to be admitted to the bar for your state.

If we take on the matter as attorneys (rather than as lay advocates), we do have to be admitted to practice in the jurisdiction for that case. In those instances, we associate local counsel to assist with following the local rules and to sponsor our admission to that state’s bar for purposes of that particular case. That is called being admitted pro hac vice (for purposes of that case).

There are a few things to keep in mind. If you want us to help you with your appeal, you’re not going to be obligated to file any type of lawsuit or arbitration or other type of litigated solution to the dispute. You’re also never obligated to keep us as your attorneys if you wish to file such an action; in fact, we too retain the right to not move forward with a litigated case and, in some instances, we may be unable to take on that representation because we may be witnesses to the payer’s conduct.

So. yes, he might very well be able to help you even if you live out of state.

There is a lot of great stuff to read there, so I’d encourage you to spend some time at his site. He has an entire paper on getting your insurance carrier to approve you. I’m going to read that tomorrow and report back as well.