Has anyone used a company to appeal a denial?

Eztli

Active Member
Joined
Oct 21, 2016
Messages
25
I was denied by BCBS for revision from VSG. I understand that I can appeal myself, however, with the way that my insurance company has been behaving Im not really sure if it'd do any good. I found a company online "Lindstrom Obesity Advocacy." This is their website: https://wlsappeals.com. I would greatly appreciate anyone's experience with them.

The longer version:
I gave Kristina (Dr.Kesheshian's assistant) all my information in February. She had to submit it 3 times. The first time, they "lost" it. The 2nd time, they sent her the paperwork back with everything that they had copied down misspelled. Like one letter off in the hospital name, one letter off in my name, misspelling the surgeons name, etc etc. The 3rd time they sent me a denial, siting 1. My BMI is not 40 or greater. Fine, except it is, according to my own calculations, googles, and the dr's office. 2. I do not have comorbidities, except I do, including exceedingly high cholesterol (hyperlipidemia) and pre diabetes. 3. Lack of medical necessity, this is debatable, but the reason I was going to Dr.Kesheshian in the first place is because he was going to try and surgically fix my heartburn (its a complicated procedure on a sleeved stomach, but it can be done). 4. Lack of documentation that I was given post sleeve diet instructions and followed said diet. This is complicated, but a) I got sleeved in another country (not Mexico), b) I was sleeved after I had lost almost 200 pounds, so I was sleeved at a normal weight and c) it was like 10 years ago and the hospital in question is not even sure it has my records.
I am so frustrated with them that I am not even sure how to respond.
Dear Profound and Enduring A**holes, I am sorry math is difficult for you, but my BMi is indeed 40. I am duly sorry you failed basic reading comprehension in grade school etc, etc, ad nauseam.
I know I have an extremely complicated situation. So I am also considering self-pay with Dr.Kesheshian or going to Mexico if Dr.Esquerra thinks he is able to surgically intervene on a sleeved stomach to correct GERD. I have also considered getting the surgery and then appealing with my insurance company for reimbursement, but frankly this doesn't sound like it'd be fruitful endeavor.
If anyone read all that and has an opinion on how is best to proceed, I'd greatly appreciate it.
 
Lindstrom has been around for a while.

Before you run out and hire them, post your EOC here. The first step is always to read the actual document. And all BCBS policies are not the same. It should be in the neighborhood of 100 pages or so.
 
Here are some basics:

1) If you have already been denied, and you have the $$ and are willing to take the relatively small but real risk of losing, you can self-pay now, and appeal while you are recovering. One denial = your right to appeal is vested. You may end up being reimbursed.

2) It matters what your EoC says, what kind of plan you have (self-funded or fully-funded), and what state law applies. CA law for fully funded plans are appealed to the DMHC which is generally the most helpful.

3) Contact @Larra and me through the conversations, where we will give you our email contact info - it is much easier to communicate by email for sharing documents, getting notifications, etc. (@southernlady - I haven't been getting ANY BF notifications for many months). Have as many of the following documents available as pdfs or links as you can:
  • Your EoC - you may need to get it from your HR dept.
  • Your bariatric policy
  • Your denial letter
  • A copy of Dr. K's letter of medical necessity/request for preauthorization
I will not say anything about Lindstrom's services. But ours are free, and I would be willing to bet we win at least if not more often.
 

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