Need Help Please. Lawyer or Advocacy.

I am a failed Lap Band patient. I am seeking a revision to sleeve. My insurance says it does cover the sleeve even though the site and policy state they do. I have been reading on this subject of being denied. While searching for help I ran across a place in California. That is across country for me. The place is Lindstrom. Has anyone used them and could give a review and cost? Is there a place that will fight for me?

I can supply more info upon request.

Thanks

Mike

After initially being denied surgery by the insurance company, I contacted the Lindstrom office. During the initial free consultation with Kelly Lindstrom, she explained to me how the appeal system works in my state and provided enough insight into the process that I was able to get the problem resolved on my own.  It was very beneficial, but I did have an edge due to my knowledge of contract law and business practices.

She was very knowledgeable, pragmatic, and professional, but also had an understanding of the emotionally charged cir****tances surrounding WLS.  I believe she handles the marketing and administrative aspects for the firm and Walter Lindstrom is the attorney in charge. I suggest you contact the firm for more information, particularly their level of experience dealing with cases in your state as the laws on some issues vary from state to state. The initial consultation is free, so you have nothing to lose.

 

Sorry, but I don't get what you mean here...

My insurance says it does cover the sleeve even though the site and policy. state they do.  

What stage are you at?  Have you received a denial?  If so, what did the denial state?  Were you denied because you're seeking a revision?  Were you denied because you didn't meet their criteria?

Need more information to answer your question!

Mary

I went to the doctor office for abdominal pain for 3 weeks. They did an endoscope and all looks good.  I weighed 10 pounds less than the weight before surgery. I thought there was a band slip or erosion. There is nothing wrong with the band per the doc. They have me going for a upper GI and barium swallow Monday morning. While at the docs I asked the insurance coordinator called my insurance to check for a revision from Lap Band to sleeve. She advised that the insurance does not cover the sleeve. she said that there is nothing they can do further to get a conversion to sleeve and that the only option is self pay. 

Here is some documents pertaining the sleeve:

http://www.gbmc.org/workfiles/ManagedCare/BlueLink_201304.pdf        page 4--- 7.01.036

http://obesitycoverage.com/bcbs-carefirst-maryland-weight-loss-surgery-coverage-requirements/

http://carefirst.staywellsolutionsonline.com/RelatedItems/135,80

https://www.bcbsal.org/providers/policies/final/053.pdf    page 3 just for Alabama  since I am here.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ncd103c1_Part2.pdf  (medicare)

http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=57&bc=AgAAgAAAAAAA&ncdver=3 (medicare)

 

I do not have medicare. If medicare says its a covered procedure and not "investigational" or "experimental" don't you think that other insruance carriers is covering it.

 

Please le me know if you need more information. I will be speaking to my doctor's office after my testing on Monday. I will see if the doctor himself witll construct a letter supporting my claim for revision since the band is not working. I am having uncontrollable hunger. I feel like I can eat like a horse every few hours and I do because I am starving and I feel like my sugar is dropping.  I think this is pre diabetic symptoms ie: hypoglycemia.

 

Thanks again for the reply. 

 

Mike

ni,other insurance companies DO NOT have to cover it just because Medicare does,not at all.

if a slip or an erosion can't be provenby testing,the insurance company can say there is nothing wrong with. The band ,but there is something wrong with the patient. They can deny revision of that alone,sorry to say.

 

your insurance company might cover the sleeve but your EMPLOYER might not have bought the rider for its employees that will cover. It is two different things. You need to find out that first.

lindstrom is an excellent advocacy group. They are actually lawyers. A phone call consult,often free, will allow them to tell you if they can help. Hiring them is not outrageously expensive and they will let you pay so much and do so much work till the fee is paid and they complete the work.

gl

These are just my thoughts - not legal opinions!

Holly might have hit the nail on the head.  Are you insured through your employer?  If so, check with Human Resources to see if they have excluded Bariatric Surgery from their coverage.  (Mine did exactly that - I had to put off surgery; I now have different coverage so I'm all set.)  If that's the case, there's nothing you can do other than pre-pay or try to obtain different coverage.

I checked the sites you provided, and the surgery is covered, with certain criteria.  Criteria is pretty basic, so I think Holly is right.

My only other thought is maybe it's not covered because at this point your doctor says "the band has not failed" - but I wouldn't count on that. 

So first, check with employer about the possible exclusion.  If there's no exclusion, I'd say contact the lawyer's office.

Hope things work out for you.

Mary

 

 

Some plans only cover one WTL procedure per LIFETIME. That is what my health insurance is like.   Just one other thing that may be the reason for no coverage.