Answers To Frequently Answered Questions

We accept cases for denials of all recognized forms of weight loss surgery including:

• Roux-en Y (RNY) Gastric Bypass
• Vertical Sleeve Gastrectomy
• REALIZE Band
• BPD/DS (Duodenal Switch)
• LAP-BAND. (If you are denied LAP-BAND surgery we are involved in a special appeals program. Contact us for additional information.)

You are entitled to have someone help you appeal an insurance denial regardless of the type of health insurance plan you have. You can designate us as your “Authorized Representative” with regard to your insurance appeal and the plan must work with us on the matter. Appeals are not legal proceedings so the good news is that you DO NOT have to hire a lawyer to get the best Advocate for your case.

If you have any doubt about your situation whatsoever you should just pick up the phone and call 1-877-99-APPEAL so we can help sort things out. If you know you have been denied DO not wait before contacting us! We should be your first e-mail or telephone call after your insurance company says “NO” the very first time! We like to get the case as early as possible. You can certainly contact us when you’re in the process and before you’re denied. We can help then too.

If you heard about our office from your bariatric provider it was because they were trying to help you in the best way possible.  A provider’s rights to appeal are somewhat more limited than that of a patient and so many providers don’t feel comfortable with the process.  Your surgeon did not do a psychological evaluation – you were sent to a qualified professional for that.  Your surgeon did not do a nutritional evaluation – you had that done (or will) by an expert dietician or nutritionist.  Your surgeon wants you to have the best care possible when you have co-morbid conditions so he/she may refer you to other doctors who specialize in those conditions . . . there’s no difference with regard to our office helping with your appeal.  Just as health care providers have their specialties and expertise, so too do they have their limitations – and fighting with insurance companies certainly is NOT a subject taught in medical or nursing school!  We will work directly with your providers to be sure everyone is on the same page so rest assured they are in no way abandoning you.  But ultimately YOU are the one responsible for fighting for your health and quality of life and by getting us involved you are putting yourself in the best chance of winning that fight.

Absolutely! Regardless of whether you need to have the same procedure revised or fixed (e.g. repairing a dilated anastomosis or stoma in RNY gastric bypass), or you need to have your first procedure “converted” to a new procedure (e.g. converting an adjustable gastric band to a sleeve gastrectomy), or adding a second bariatric procedure to your first (e.g. placing an adjustable gastric band “over” a RNY gastric bypass), we can help you win your insurance company says “NO”.

Unfortunately many insurance companies and self-insured plans attempt to limit patients to “one surgery per lifetime” or deny revision procedures based on their belief that you, the patient, were “non-compliant” after your first procedure. It gets back to their old mentality of “let’s blame the patient.” Regardless of the reasons, you should contact us to evaluate how we may be able to assist getting that revision approved.

We also handle denials for reconstructive surgery which is often medically necessary after massive weight loss. We can also work with your reconstructive surgeon’s office to help them fashion their request for coverage to the insurance company in a way that maximizes your chances of getting approved.

Our fees vary depending on the extent of service you need but generally they are only in the hundreds of dollars – people are shocked at how much we do for such a reasonable fee. All of our appeal services are performed on a fixed fee basis (NOT on an hourly rate based on our time spent on the appeal) so you know exactly how much you have to pay and and we are happy to work with you so that fees are never an obstacle to you getting the help you need.

Yes! We are quite successful getting many patients some or all of their money back when they have paid cash for a procedure wrongly denied by their insurance company or self-insured plan.

Yes! While most denials stem from a bariatric surgeon or program’s request for approval after they have determined a patient is a candidate for surgery, there are times when a patient cannot even get into see the surgeon to have that evaluation done because the insurance company “gatekeeper,” whether it is an HMO plan or otherwise requires a referral to the surgeon and that referral is being denied. We can help get you to the surgeon so they can make the medical determination if weight loss surgery is right for you – - after all, they are the experts and you should not be denied access to them!

You would be surprised how many times people are told that they have an exclusion for surgery but when we review their certificate of coverage or other insurance documentation no such exclusion exists. However there are times when there is contract language that says something along the lines of “We don’t cover any form of weight loss surgery…” As part of our FREE CONSULTATION with you we will evaluate your case, the contract language in determine if we think we can help. We will tell you the truth and not accept your case if we don’t think we have a reasonable chance of helping you.

“NO!” By saying that we don’t mean to be critical of what your doctor’s team recommends. Most surgeons’ offices mean well and sincerely try hard to avoid denials by complying with insurance company criteria, no matter how unreasonable the criteria might be. We think there is too much risk in waiting. It can be really dangerous to wait for a couple of reasons. First, your health may suffer if your co-morbid conditions worsen or you develop more of them. Second, there is the chance your insurance plan or coverage may change while you are on their mandatory supervised diet. If your plan changes to an exclusion of all surgery, you may lose out on any chance to get approved!

There is little medical evidence to support these supervised diets over 6-12 months. If you don’t believe us, here is what the American Society of Metabolic and Bariatric Surgeons (ASMBS) says in its Position Statement on Preoperative Supervised Weight Loss Requirements:

“It is the position of the ASMBS that the requirement for documentation of prolonged preoperative diet efforts before health insurance carrier approval of bariatric surgery services is inappropriate, capricious, and counter-productive given the complete absence of a reasonable level of medical evidence to support this practice. Policies such as these that delay, impede or otherwise interfere with life-saving and cost-effective treatment, as have been proven to be true for bariatric surgery to treat morbid obesity, are unacceptable without supporting evidence.”