Please fill out the form below so we can evaluate how best to assist you.
 
This information is kept confidential and secure and will not be sold, distributed or shared in any fashion with any persons outside of the Obesity Law & Advocacy Center or Lindstrom Healthcare Advocacy, Inc.
 
PERSONAL INFORMATION FOR PATIENT BEING DENIED ACCESS TO CARE
First Name*
Last Name*
Please check the response closest to your situation*
I have not had surgery yet and I want to appeal their denial
I decided to pay cash after insurance denied and I want to get money back
I had surgery after I was told I was approved but now insurance is refusing to pay
How Did You Hear About Our Office?*
Referred by my surgeon's office
Referred by my primary care doctor
Obesityhelp.com
Web Search Engine
You Represented Someone I Know
Obesity Action Coalition
American Society For Metabolic and Bariatric Surgery
I saw you quoted in a media article
I read something you wrote
Other
Personal Email Address*
Work Email Address (if different)
Home Phone*
Work Phone
Cell Phone
Fax
Address*
Unit/Apartment/Suite
City*
State*
Zip Code*
Date of Birth (MM/DD/YYYY)*
Insurance Company/Plan Which Denied You*
INFORMATION REGARDING INSURANCE COMPANY OR PLAN DENYING COVERAGE
Date of Insurance Denial*
Was the denial in writing or over the phone?
It was in a letter sent to me
It was in a letter sent to my surgeon's office
It was denied over the phone and there is nothing in writing
It was denied over the phone and I am supposed to be receiving a letter in the mail
I don't know
Insurance ID #*
Do you have a copy of your insurance coverage booklet (this may include web access through the company or your employer rather than a hard "booklet")?*
Yes No
Type of Surgery Denied*
Roux - En Y Gastric Bypass (RNY)
Vertical Sleeve Gastrectomy (VSG)
Duodenal Switch (BPD/DS)
Mini-Gastric Bypass (MGB)
LAP-BAND
REALIZE BAND
Vertical Banded Gastroplasty (VBG)
Reconstructive Surgery
Endoluminol Procedure (ROSE; StomaPhyx, etc.)
Other
What reasons did the insurer give in support of denying surgery?
Insufficient Supervised Weight Loss History
Did not show a long term history of obesity (e.g. 2-5 years)
The procedure I want is "experimental" or "investigational"
The provider I want is not in their network or is not a Center of Excellence
My BMI is too low and/or my co-morbid conditions are not severe
No weight loss surgery of any kind is covered (Contract Exclusion)
Not Medically Necessary (no other details were given to me)
Not a Covered Benefit (no other explanation given why not)
They only cover one weight loss surgery per lifetime
I do not meet their criteria for a second weight loss operation
What is your height?*
What is your weight?*
Have you or your surgeon's office appealed any denials so far?*
Yes No I don't know
Have You Ever Had A Prior Weight Loss Surgery?
Yes No
If yes, what kind?
Roux En Y Gastric Bypass (RNY)
Vertical Sleeve Gastrectomy (VSG)
Duodenal Switch (BPD/DS)
Vertical Banded Gastroplasty (VBG)
Mini Gastric Bypass (MGB)
LAP-BAND
REALIZE BAND
Other
Please identify what co-morbid diseases you have been diagnosed with:
Type 2 Diabetes
Obstructive Sleep Apnea
Hypertension (High Blood Pressure)
High cholesterol or High Triglycerides
GERD (Acid Reflux Disease)
Arthritis / Joint Pain
Urinary Stress Incontinence
Depression and/or Anxiety
Edema (Swelling of the lower joints)
Hypothyroidism
List other conditions here:
What is the name of the weight loss surgeon or surgical program where you wish to have (or did have) your surgery performed?*
City and State where they are located*
Briefly tell us anything else you believe might help us understand your situation.

 
* Indicates field is required.