Insurance says DS investigational: a how-to manual

I have received a number of inquiries lately about how to deal with this insurance stupidity, so I thought I would post it here rather than repeat it over and over in PMs, since the general process is pretty much the same for most insurance companies.

*  First, figure out if your insurance company covers WLS at all.  You can usually find this on the insurance company website.

* If they do, get a copy of YOUR policy to see whether they cover WLS, as employers can opt out of certain coverages. 

* If they do, find out (from your HR department) whether your insurance plan is fully funded or self funded.  It makes a difference in your route and right of appeal.

* If you find out that the insurance company covers WLS BUT says the DS is experimental/investigational, this is what I have found is the way to proceed:

* Ask your PCP to refer you for WLS, and be a good little sheeple and follow all the rules.  Don't mention your desire to get the DS at this point.   * What you are trying to do FIRST is to get yourself approved for WLS in general (likely the RNY), so that when you start to fight for the DS, you are only fighting for WHICH surgery you should have, not whether you qualify in the first place.  If you start out asking for the DS with a company that has an exclusion of the DS in their policy, they will make your life miserable at every turn to try and keep you from getting approved for WLS in the first place -- they will get hypertechnical with the 6 month diet requirements, with the proofs of being MO for 5 years, etc.  They are generally less picky with the RNY sheeple. * Note that in CA, you can avoid the 6 month diet or 10% weight loss requirement by immediately appealing to the CA Dept. of Managed Health Care.  But if you don't fast track that appeal, it will take 4-6 months anyway.  I can help you get in contact with the right people at the DMHC if you have one of these stupid requirements. * While you are in the approval process for WLS, find yourself a DS surgeon.  Get a consult, and pay out of pocket for it.  Get a letter written for you by the DS surgeon that explains why the DS is better for YOU than the RNY.  This can be because you are SMO, have a family history of stomach cancer, have arthritis or other reasons to need or expect to need in the future to take NSAIDs, have the need to be on anticoagulants, have a Nissan wrap, or some other PERSONALIZED reason.  You may as well get the psych consult out of the way at the same time. * In the meantime, you will be writing your request for the DS for after you are approved for the RNY.  You are gathering the papers that show the SUPERIORITY of the DS to attach to your request. * When you get approved for the RNY, you IMMEDIATELY submit your request for the DS instead, including the well-written letter with your reasons why you want the DS, copies of the scientific literature supporting your reasons, and the letter from the DS surgeon recommending it for you in particular. * The insurance company will take every day of the permitted period to deny you.  You will try not to take this personally (HAH!). * You will take their denial, and IMMEDIATE submit a request for a second level review.  It will essentially be a copy of the first well written letter, with a request for reconsideration.  You will maintain your calm, because there is NOTHING personal about this -- it is business (note that I was completely unable to follow this rule and wasted a lot of unnecessary emotion on this part of the process). * The insurance company will take every day of the permitted period to deny you again. * What happens next depends on your type of insurance, and possibly which state you live in.  If your plan is self-funded, the company ultimately has the power to overrule the insurance company, and your route of appeal is through the company's HR dept.  If your insurance is fully funded, then you likely have the right to external medical review -- that information should be provided to you in your second level denial. * In CA, that review is generally to the CA Dept. of Managed Health Care, which is VERY pro-DS.  The process takes about 30-60 days (I believe it's 30 days from when the DMHC gets a copy of your medical records and appeals from your insurance company), and at the end, they overturn the denial in most cases.  The process may vary in other cases, but the important thing is that EXTERNAL medical people will review the case. More and more, the external medical reviewers are overturning the denials.  Don't let the insurance companies dictate how you are going to live the rest of your life.

Diana, Thank you sooo much for this information.  I have Cigna insurance and they specifically exclude the DS surgery and sleeve gastectomy as experimental/investigation or cite insufficient peer-reviewed studies. My policy is self-funded and I know that exempts it from the obesity laws in the state of Maryland.  I have my consult on February 4. Again, thanks to everyone on this board for being so supportive and informative!! Kathy

I've bookmarked it!  Thanks for being so thoughtful and writing this all up. 

Excellent information.  I've bookmarked it too.

Hey diana, I cut and posted this in my OH blog....I know normally you don't mind....I did give you credit, and will put the link to this thread in my post.. I just wanted to let you know, incase you had any objections. Scott

Diana , Thanks so much! This has helped me. I know that I have done the right thing so far! :) I have my appeal pretty much written, a letter from my pcp, a letter from my psych (I love Dr. BIll Hartman) I just had my cardiology consult and he agreed to write me a pro-ds letter!!! I did my sleep study and found out I have sleep apnea, I just have my follow up appointment. All I have left is an appt. with Dr. Jossart!!!! Then I will mail off  my appeal the DMHC! Its good to know that they tend to overturn denials.   I do have a question though. In my appeal I also share some intances where the DMHC overturned peoples denials to allow them to have the DS. Do you think that is a good idea? I'm getting nervous but a good nervous!!!!!! I've bookmarked this page!!  Mucho Besos Maya

Diana, thank you SO VERY MUCH for this wonderful information!!!  Just knowing how to proceed really takes a load off of my mind--I can calm down now!  I called to schedule a physical with a new PCP as the one I have currently is lousy--it's not till March 11th, but I'll live   I've decided that once I have my initial visit I will schedule another appointment with her discussing my weight, and go from there.  Now at least I have the plan of action to follow!  Thank you again, you're awesome! ~Tara

THANK YOU for the information! Bookmarked.

I would ask your doctor to submit your request for WLS NOW (not asking for the DS specifically), and get the denial for lack of doing the six month diet, and appeal.  But instead of JUST appealing through the insurance company's internal review process, after you get the FIRST denial, I would get the forms from the DMHC and file a GRIEVANCE, not a request for IMR, to get them to force Health Net to drop the diet requirement. Here is the DMHC document that establishes that there is no proper basis for requiring a diet: http://www.hmohelp.ca.gov/boards/cap/bariatricrev.pdf

SUMMARY CONCLUSION

There is no literature presented by any authority that mandated weight loss, once a patient has been identified as a candidate for bariatric surgery, is indicated. There is a mixture of results that question whether weight or truncal obesity is a risk factor for complications after bariatric surgery. The more analytic studies have not found that body mass index (BMI) or total weight is an independent risk factor for complications or death from bariatric surgery.

No institution that has recently published data on bariatric surgery describes a protocol requiring weight loss between identification of the need for surgery and the surgery. Many institutions in California have published results of surgery with particular focus on factors that contribute to morbidity and mortality. No paper from a California institution mentions mandated weight loss before bariatric surgery. Nor does any literature regarding the treatment for the morbidly obese recommend continued weight loss during the period between identification of the need for bariatric surgery and the surgery.

Mandated weight loss prior to indicated bariatric surgery is without evidence-based support. Mandated weight loss prior to indicated bariatric surgery leaves the patient at increased risk from the patient’s comorbidities. Mandated weight loss prior to indicated bariatric surgery is not medically necessary. Mandated weight loss prior to indicated bariatric surgery would be deviant from the standard of care practiced in the United States and other published countries. The risks of delaying bariatric surgery, while not entirely known in the short-term, are real and can be measured. Any potential value of losing weight prior to bariatric surgery is theoretical and not supported by any data. An experimental study including fully informed consent to determine if there were a reduction in risks or other benefit from mandated weight loss prior to bariatric surgery is indicated.