External appeal

Has anyone had success with an external appeal. My situation is this: I had lap band in 2005 and am now seeking a revision to DS. My insurance has denied me twice so now it has to go to an external appeal, which is done in Virginia by The Office of the Managed Care Ombudsman (I believe this is a state agency). The external appeal is my last chance and the decision is final. I am really worried I will not be successful. In my eyes, I see the revision as medically necessary, but my insurance does not, and so I'm not sure how the external appeal will go. Long story short, my insurance keeps denying me because they say I was not compliant with the band, even though my band doctor wrote a letter saying I am. I recently found out my band is slipped and I continue experiencing horrible acid refulx yet they still deny me.

I would be grateful if anyone could share their external appeal experience with me.

Thanks!
Ann-Marie

I am about to do the same.  I have contacted Walt Lindstrom to assist me in my appeal.  I have letters from 2 surgeons, primary care dr, chiropractor, and pych dr all stating this is medically necessary and they are denying mine!!  Good luck

The Lindstroms wrote my appeal letter for me and are handling my external appeal as well. They are really great. So let's hope we both get approved!

Hi,

Newbie here also with insurance denial issues, specifically with VSG.  May I ask who are the Lindstroms and do you think they might be appropriate for me?  I live in CA and have Anthem Blue Cross.

Thank you in advance.

What's the reason for your denial?  Investigational?
If so, there are letters around others have used to successfully appeal via the Dept. of Managed Care.

Thanks for your answer, Yup on the denial reason. I have just found a couple of VSGers who gave similar advice.  I've got some wrtiting to do!

Good luck!

 Hi there-

I know your post is many, many months old, but I just wanted to ask you a few questions about your external appeal.  I am trying to revise from RNY to DS and have Aetna.  My plan does not pay for out-of-network coverage for bariatric surgery, and all of the DS specialists who do revisions are out-of network.  After my first appeal was denied, I contacted Walter Lindstrom.  He wrote a kick-butt letter to Aetna that I thought for sure would get me approved, but they denied me again just yesterday for the same reason (no out-of-network benefits for bariatric surgery).  I believe our next step is the external appeal.  Can you tell me how long that particular process took for you?  I'm so glad to see that you finally got your DS!!!  I hope to be able to say the same eventually!  I'm so miserable!!

Sandy

Hi Sandy,

My external appeal was submitted at the end of June and I didn't hear anything until September. It seemed to be forever! It was worth it though because I was approved! Good luck!