NuttyMoonBride

I'm Filing an External Review, should I hire Lindstrom Obesity Advocacy?

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Greetings: 

 

For those of you who have followed my topic "Aetna Anyone"   and "Appeals, Appeals, Appeals"  know about the grief Aetna has been giving me due to my High Blood pressure being under control with two medications and my pre-diabetes being not being developed to full blown diabetes.   Since my Level 2 Appeal was denied, I've been thinking about hiring the Lindstrom Obesity Advocacy to represent me on my External Review.  Basically, they will write an appeal letter which includes:  a case analysis, and exhibit, which consist on outlining the reasons the denial should be overturned, backed up by medical literature and my 3 years of medical history, 2 hospitalizations as a result of hypertension and a minor heart attack in 2009. and finally an aggressive follow up.   They claim that once the patient utilizes them to represent them, " the insurance companies usually overturn their decision.  Lindstrom claims a 90% overturn rate.  COMPARE TO MY 2 DENIALS THE 90% seems better than my odds. :)

 

I am quite disappointed with my surgical coordinator.  I've been doing most of the advocacy for myself.  she doesnt take the initiative to follow up with Aetna, when I ask her for her opinion, she ends up asking me:  How would you like me to proceed, rather than, why don't we take this approach, have your docs do this, or to write something like this.  shenever gives me suggestions, other than i will do what you tell me to do.  Hello??? ?  To make things worst, when I asked her about the external review and all the things required by Aetna to follow the claim, she responded:   not knowing about the type of documentation that needs to be submitted etc.  I wanted the earth to swallow me.   hell broke lose and then froze over.   I said I have to get back to you.  and hang up.  I read my denial letters and they all state this:

Medical notes submitted from 2009-2013 show:

 no documentation that the member has a BMI of 35 or greater for two years along with one of the following diseases:  1) Diabetes 2) High blood pressure that is not well controlled with the use of many medications.  3) Stopping breathing while sleeping that meets guidelines for a pressure mask to wear at night (sleep apnea qualifying for continuous positive airway pressure or CPAP)  or 4)  Disease in the arteries or the heart.   This member’s BMI is less than 40 and does not have on of these four life-threatening diseases.    Although the member has a BMI of 38.4 along with a  history of hypertension,  the combination use of anti-hypertensive agents, has demonstrated a relatively well controlled disease, therefore, Gastric Bypass Surgery is not medically necessary at this time.  

 

My cardiologist submitted a documentation along with an appeal letter showing I had a minor heart attack in 2009 and  and the likelyhood I may develop dilated cardiomyopathy( enlarged heart) despite of my hypertension being controlled.  I

 

Reading their rationale for denial, makes me wonder if I should proceed with the External Review.   If so, Should I Pay the $600 busck Lindstrom is charging me and let them do the advocacy or allow my non-assertive surgical coordinator file the external review.  Time is of the essence, since I have 120 days from 12/23/2013 to file the review.  Your suggestions are really welcomed. :)  

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If you can afford the $600 I think you should go with them but before you believe the firm's success rate, maybe you should google and research reviews of their services from real people that have used their services.  Maybe some members on this forum have used them.

 

I think you should do everything within your power and control to move this forward because as you can see your advocate is not advocating the way you need.  This is so ridiculous and I am so sorry you are going through this. 

 

I say go for it if it is feasible and within reach.

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Thanks.  

After reading online reviews, reading news articles, television appearances Morning shows, and reading the Better Business Bureau of San Diego, on his law firm practice, I feel that i am making the right choice.  I called the company, spoke directly with Kelley,  I was asked to submit the agreement form along with all the medical records I have available so they can start to work on it immediately.   Out of courtesy i notified my surgical coordinator, so that she could get my records ready once Lindstrom request it, she was in agreement reporting that getting them involved was a good idea.  I don't know if she said that with my best interest in mind or just to say it, since someone else will be handling the job she was supposed to do.  Whichever way it goes, I realized too late how her lack of advocacy did not get me anywhere.  Regardless, I will keep in touch with her, because if I get approved I will still see her and deal with her.  This has taken an emotional toll on me.  But from the beginning I knew that I was not gonna give up without a fight and this is my last fight.  

 

Thanks for your words of encouragement. 

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The surgeon's insurance admin is just a clerk who files the paperwork with the insurance company, not an advocate---and certainly not one with specialized training and expertise in appeals. I'm glad that you are not going to rely on a clerk to do a professional's job, especially in our complicated medical system and with your critical need for surgery.

 

When my application was denied due to incredibly inept screw-ups by my surgeon's office staff, I had an initial (free) consultation with Kelley at Lindstrom and was very impressed.  It was probably the most helpful 20 minutes I spent in the entire weight loss process. After getting the pertinent information about my case, she was quickly able to determine what had been done wrong and what was omitted from my insurance submittal and mapped out a plan of action based on the specific circumstances. She was also quite adept at calming me down and helping me focus on getting to a solution.

 

Because I have some legal training, I was able to take Kelley's information and work through the appeal process as my own advocate. However, if I had hit any more speed bumps, I would have retained Lindstrom's services in a heartbeat. Insurance denials are emotionally devastating, so it is often best to take yourself out of the equation and let a cool headed, unemotional advocate deal with the legal and business aspects that are the crux of the problem.  Insurance is a contract matter and the companies are interested solely in facts and contract terms, not the patient's emotionalism.

 

Wishing you success with the appeal and your WL journey!

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Just curious, what is your BMI?

My BMI is currently 38.4 and I'm still 210 lbs. 

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The surgeon's insurance admin is just a clerk who files the paperwork with the insurance company, not an advocate---and certainly not one with specialized training and expertise in appeals. I'm glad that you are not going to rely on a clerk to do a professional's job, especially in our complicated medical system and with your critical need for surgery.

 

When my application was denied due to incredibly inept screw-ups by my surgeon's office staff, I had an initial (free) consultation with Kelley at Lindstrom and was very impressed.  It was probably the most helpful 20 minutes I spent in the entire weight loss process. After getting the pertinent information about my case, she was quickly able to determine what had been done wrong and what was omitted from my insurance submittal and mapped out a plan of action based on the specific circumstances. She was also quite adept at calming me down and helping me focus on getting to a solution.

 

Because I have some legal training, I was able to take Kelley's information and work through the appeal process as my own advocate. However, if I had hit any more speed bumps, I would have retained Lindstrom's services in a heartbeat. Insurance denials are emotionally devastating, so it is often best to take yourself out of the equation and let a cool headed, unemotional advocate deal with the legal and business aspects that are the crux of the problem.  Insurance is a contract matter and the companies are interested solely in facts and contract terms, not the patient's emotionalism.

 

Wishing you success with the appeal and your WL journey!

 

Thank you, your words came at the right time and moment.  Kelly was amazing.  I regret not getting them involved earlier in the process. 

They are always available, answer emails promptly and provide me with follow ups.   I am just careful of not getting my hopes up, as you said, this is emotionally draining.  

Once again, thank you. 

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hi. just wanted to say that i was turned down by my insurance company also. said i was not fat enough long enough. i hired the lindstorm group. they were great. i was approved a week after they submitted my appeal. i used my vaca money but it was worth it. they are the nicest people.  i have not regretted hiring them. i have lost 50# since surgery. would have lost more but was in a cast for the last 6 months. good luck. hoping this works out for you as it did for me. keep us updated. 

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I hired them for my appeal. They were great and I was approved a week after submission and my case was not an easy win. I was a revision case and the appeal letter brought tears to my eyes. The financial sacrifice was worth it. 

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Thanks all for your replies. It is motoring to know how helpful they are. I am hopeful.

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Good luck NuttyMoonBride! Been pulling for you all along, glad to hear you haven't given up and are moving forward with the legal help! Jen

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I am delighted to inform that Lindstrom Advocacy made it possible for the EXTERNAL REVIEW to overtutrn Aetna's denial,.  I am Approved.  As of today. I am Approved. 

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Congratulations!

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Congratulations!

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wow, i just noticed that you were approved, so excited and happy for you, do you have a date yet?

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wow, i just noticed that you were approved, so excited and happy for you, do you have a date yet?

 

 

THANK you.   

Yes i do.  it will be on May 7th.   

im so excited  :D  :lol:

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I'm so happy for you!  YAY!

Thank you.  

After reading your post about Kelly,  I contacted them  and began the process.    By February 25, the external review was filed.   By March 10, Aetna and IMEDICS notify me that my case was deem eligible for review.   By march 27 I was approved.  by March 29, Imedics sent me the official letter overturning aetna's decision.  Kelly told me that it takes Aetna 7-10 business days to upload the information in their system and to mail out the approval letter.  She assured me that she will continue to follow up with Aetna, until she receives the approval letter.  Once that letter is received. my case will be closed.  i honestly regret not getting them involved earlier in the process.  

thank you very much for your support!!!

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Congratulations! What an incredible victory and an exciting step in the right direction. Best of luck to you :)

 

Chele

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THANK YOU 

:)

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Does the appeal process seem long?

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After my initial denial by Cigna I hired Lindstrom Obesity Advocacy to handle my appeals and am happy to say that my denials were overturned on independent review.  My surgery is now scheduled for 10/7/15.  Kelley was wonderful, always available to me and always on top of the appeals at every turn.  She kept me informed of any progress as soon as it developed.  She really seems to care about her clients.  I highly recommend using them. 

 

My first denial was in June and the denials were overturned in August on independent review.  My surgeon's office commented on how fast the process was compared to the experience of others in their office.

 

There were three levels of service options.  I chose the most expensive which included their office collecting all my medical records on an expedited basis, preparing a wonderful appeal letter citing medical findings and things I could never have done on my own, and following up with Cigna and the independent review people.  As someone mentioned before, it took me out of the equation and saved me the additional stress or record collecting and follow up phone calls. 

 

They cannot guarantee a positive outcome but they know so much more than the lay person does with regard to the process and have the knowledge and experience needed to get the best result possible.

 

It was the best money I ever spent and I am over the moon that this worked out for me.  My recommendation is don't wait to contact them.  I contacted them immediately after I got my first denial and they handled the rest. 

 

So that's my two cents!

 

Good luck to everyone!

Edited by bettybuyin

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I am here to throw a Ditto to what BettyBuyin posted. I just got the call yesterday from Kelly at Lindstrom. Initial denial in June, next one in July. I hired Lindstrom immediately and paid for their highest level service. Worth every penny. They handled getting all of my medical records, the letters to CIGNA, the letters to the State of Tennessee (who wrote in some policy that they had the power to deny based on X, Y, Z). 

The process wasn't as quickly as I had hoped, but once it got rolling, it went quickly. We had the 2nd level appeal review last week with the Medical Doctor for CIGNA. Based on that, they overturned their denial and it was approved. It just took a bit to get to that meeting. 

Surgery currently scheduled for next Tuesday before they can change their minds! LOL

To summarize - if you are thinking about hiring Lindstrom Obesity Advocacy group - do it. It's worth it. They know what they are doing, what to ask for, what to push...and it was a completely stress free process from my end. Paid them, and they did all of the work. 

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Hi I am new to this group and I seen you mentioned TN? I am from TN and having some issues with cigna. They told me wls was not covered. I tried to asked what the requirements were since my dr is suggesting the surgery. I got cut off in mid sentence saying it doesn't pay at all. Any advice would be helpful...I'm thinking about not  going to my appt. My BMI is 46 and I have type 2 with other health issues that are caused by weight.

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I was denied by Cigna and I hired Walter Lindstrom. They took my denials right through to the final external appeal which I am happy to say was finally approved. Kelly Lindstrom was wonderful to deal with and always available and Walter handled the appeals brilliantly. They know what they are doing as they have quite a bit of experience doing it. Cigna continued to deny me right through to the external review so don't get discouraged. Kelly is also there to bolster you up when the denials get to you. Happily I had my sleeve gastrectomy in December and I have lost 65 lbs. to date and am still going strong. Although the Linsdstoms can't guarantee an outcome they take all the guesswork out of it and give you the best representation possible. I don't regret a bit of that money spent!  Go for it and good luck!

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