what are the qualifying comorbids with DSHS? Help!
My husband and I are going back to school full time and we'll be on DSHS for our health insurance. I don't have diabetes and I'm not sure my knee would require replacement surgery. So, what are some other comorbids that DSHS will approve of? If you had a the surgery and used DSHS or medicaid, please share your qualifying comorbid with me.
I do have sleep apnea...does that count?
Heidi
I do have sleep apnea...does that count?
Heidi
Hi Heidi...
I guess it would depend on where you will be opting to have the surgery. However, I might have some information that might be useful to you.
This is by no means any type of council but, just information that might help you out. Please make sure to call DSHS directly and understand what they need from you. But again this post is just for informational purposes...I hope this helps
{Quote}
RE: Referral to the University of Washington Bariatric Clinic Washington State DSHS (Medicaid) Guidelines for Bariatric Surgery
Dear Interested Candidate: If you have Washington State Medicaid (DSHS) as your primary health coverage, the following letter contains useful information necessary to proceed with Bariatric surgery at the University of Washington Medical Center. Please note that these requirements were created by the Department of Social & Health Services and NOT the UWMC. Washington State DSHS guidelines must be followed to ensure that your bariatric care is covered financially at the UWMC. Please read through the individual steps/requirements/criteria below.
Stage 1 (Preliminary Approval) You MUST meet the following requirements. If you do not, then you do not qualify for bariatric surgery under DSHS regulations and Washington State Medicaid under no cir****tances will pay for this type of treatment. Criteria: Age -You must be between the ages of 21 and 60. Body Mass Index (BMI) - You MUST have a BMI equal to or greater than 35. (This number is determined by your primary care provider or by using standardized BMI calculators that can be found on the internet.) Medical conditions/Co-morbidities – You must have ONE of the following conditions:
o Diabetes Mellitus Type II requiring medication and/or;
o Degenerative Joint Disease of a major weight-bearing joint(s), such as knees or hips, requiring joint replacement (excludes arthritis in back or Degenerative Disc DiseaseYou must NOT have multiple sclerosis (MS), whi*****reases risk of mortality. Please note: the only exception to these medical conditions is a rare brain disorder called pseudo tumor cerebri that must be documented by a physician. While there are a number of other medical conditions that are often a result of obesity, they do not qualify for gaining DSHS (Medicaid) approval. In the case that your condition does not satisfy the requirements for approval, we recommend you continue to explore other options with your primary care provider to find a non-surgical weight loss solution. Those who do qualify with the above criteria should contact their Primary Care Provider to complete Stage 2 of the DSHS process. Stage 2 (Pre-Surgery Stage)
You and your Primary Care Provider (PCP) must complete the DSHS application to Stage 2 approval and fax your medical records to the DSHS committee for review. The Washington State DSHS phone number is 360-725-1584. The DSHS fax number is 360-586-1471. DSHS will provide a ruling on your request. You will receive an official letter from DSHS with the approval or denial of your request.
When/if you receive a letter of approval, you need to begin work with your PCP on the next step of Stage 2: the Diet and Exercise requirement. Diet & Exercise – You must participate in a 6-month medically supervised weight reduction program, and must lose 5% of your weight in that time. (Example: If you weigh 300 pounds, you would need to lose at least 15 pounds during the six months). In addition, you must maintain the weight loss until surgery. During these 6 months you must also: See a supervising physician, (usually your PCP) once per month for 6 months; See a registered dietitian twice monthly for 6 months (Your PCP can help you find someone); Maintain a journal of consistent diet and exercises completed in this time. After the completion of your 2nd month supervised weight loss, your PCP will contact UW Medicine’s Bariatric Program (Intake phone #: 206-598-2274) to enter UW Bariatric program. When we receive records, the DSHS letter of approval for stage 2, and letter of referral from your PCP including documented weight loss up to this point, we will contact you to set up appointments for the final steps leading to surgery: Bariatric Seminar – You will be scheduled to come for a required Bariatric educational seminar. Surgical Evaluation – After the seminar visit, you will be scheduled for a consult to see the surgeon who will examine you and evaluate you for the actual surgical procedure. Psychosocial Evaluation – to be completed at the University of Washington Medical Center with a licensed psychiatrist or social worker. Important! You must continue your visits with a dietitian and PCP to complete the remaining steps of the DSHS requirement while you are enrolled in our program. Stage 3 (Authorization for Surgery) Following the process above, the Bariatric Team at UW Medicine’s Center for Bariatric Surgery will complete the necessary steps for approval and scheduling for surgery. This process includes submission of all of the Stage 2 records, including the surgeon’s recommendation, to DSHS for final review. DSHS will do a final evaluation of your records and make a final determination of approval for surgery. Once DSHS has made its determination, you will receive an official letter from DSHS to inform you of your approval or denial to Stage 3. If approved, you will need to immediately fax the UW Bariatric Team a copy of this approval letter to 206-598-6705 or 206-598-9470. Once we receive a copy of this letter, we can schedule your surgery. We hope that this letter and these guidelines listed explain the process for you and assist you in obtaining approval for bariatric surgery with DSHS insurance at UW Medicine’s Center for Bariatric Surgery. Please check out our website at www.uwbariatric.org for further information. We wish you the best in your efforts.
Sincerely,
The Bariatric Team
UW Medicine Center for Bariatric Surgery 4. Make sure you correctly understand specifically what your insurance requires. If something is foggy - get clarification in writing!!!
5. If you have a 6 month or year doctor supervised weight loss requirement make sure it is more than complete! My doctor just had my weight, blood pressure, height, and stated following diet, or still dieting. That wasn't enough! I was denied! They want it spelled out clearly such as: patient is following the Weigh****cher diet plan under my supervision - they want a specific plan you are following. They want behavior modification notes: such as patient is drinking at least 8 - 8 oz glasses of water a day, eating only lean proteins, no frying, limiting fats to......etc., Exercise - they want to know what you are doing and how much. Be specific and show improvement on exercise each month.
6. Most insurances want a letter from you stating your willingness to comply: List your past dieting attempts and failures, be specific with names of diets and dates. List what wls books you have read to learn from, list any support groups you have joined/are attending. List WLS on line groups you are a member of, list statistics about WLS and how it helps diabetes, sleep apnea, high blood pressure, etc. List statistics on how much longer people live after having wls. Let them know you are throughly informed and are not taking this surgery lightly.
7. State spefically why you want this surgery, how it will change your life, tell them about the vitamins, mineral, supplements you will have to take for the remainder of your life and tell them your source for purchasing them etc.
8. State any and all medical problems you have: diabetes, high blood pressure, sleep apnea, COPD, etc.
9. If you have seen any specialists - get a letter of support from them too. The more doctor's support letters you have makes it harder for insurance to say no.
{End Quote}
I really hope this helps.... I'm still trying to make it to stage 2. I'll know in 10 days I hope.
-Billie Jo
I guess it would depend on where you will be opting to have the surgery. However, I might have some information that might be useful to you.
This is by no means any type of council but, just information that might help you out. Please make sure to call DSHS directly and understand what they need from you. But again this post is just for informational purposes...I hope this helps
{Quote}
RE: Referral to the University of Washington Bariatric Clinic Washington State DSHS (Medicaid) Guidelines for Bariatric Surgery
Dear Interested Candidate: If you have Washington State Medicaid (DSHS) as your primary health coverage, the following letter contains useful information necessary to proceed with Bariatric surgery at the University of Washington Medical Center. Please note that these requirements were created by the Department of Social & Health Services and NOT the UWMC. Washington State DSHS guidelines must be followed to ensure that your bariatric care is covered financially at the UWMC. Please read through the individual steps/requirements/criteria below.
Stage 1 (Preliminary Approval) You MUST meet the following requirements. If you do not, then you do not qualify for bariatric surgery under DSHS regulations and Washington State Medicaid under no cir****tances will pay for this type of treatment. Criteria: Age -You must be between the ages of 21 and 60. Body Mass Index (BMI) - You MUST have a BMI equal to or greater than 35. (This number is determined by your primary care provider or by using standardized BMI calculators that can be found on the internet.) Medical conditions/Co-morbidities – You must have ONE of the following conditions:
o Diabetes Mellitus Type II requiring medication and/or;
o Degenerative Joint Disease of a major weight-bearing joint(s), such as knees or hips, requiring joint replacement (excludes arthritis in back or Degenerative Disc DiseaseYou must NOT have multiple sclerosis (MS), whi*****reases risk of mortality. Please note: the only exception to these medical conditions is a rare brain disorder called pseudo tumor cerebri that must be documented by a physician. While there are a number of other medical conditions that are often a result of obesity, they do not qualify for gaining DSHS (Medicaid) approval. In the case that your condition does not satisfy the requirements for approval, we recommend you continue to explore other options with your primary care provider to find a non-surgical weight loss solution. Those who do qualify with the above criteria should contact their Primary Care Provider to complete Stage 2 of the DSHS process. Stage 2 (Pre-Surgery Stage)
You and your Primary Care Provider (PCP) must complete the DSHS application to Stage 2 approval and fax your medical records to the DSHS committee for review. The Washington State DSHS phone number is 360-725-1584. The DSHS fax number is 360-586-1471. DSHS will provide a ruling on your request. You will receive an official letter from DSHS with the approval or denial of your request.
When/if you receive a letter of approval, you need to begin work with your PCP on the next step of Stage 2: the Diet and Exercise requirement. Diet & Exercise – You must participate in a 6-month medically supervised weight reduction program, and must lose 5% of your weight in that time. (Example: If you weigh 300 pounds, you would need to lose at least 15 pounds during the six months). In addition, you must maintain the weight loss until surgery. During these 6 months you must also: See a supervising physician, (usually your PCP) once per month for 6 months; See a registered dietitian twice monthly for 6 months (Your PCP can help you find someone); Maintain a journal of consistent diet and exercises completed in this time. After the completion of your 2nd month supervised weight loss, your PCP will contact UW Medicine’s Bariatric Program (Intake phone #: 206-598-2274) to enter UW Bariatric program. When we receive records, the DSHS letter of approval for stage 2, and letter of referral from your PCP including documented weight loss up to this point, we will contact you to set up appointments for the final steps leading to surgery: Bariatric Seminar – You will be scheduled to come for a required Bariatric educational seminar. Surgical Evaluation – After the seminar visit, you will be scheduled for a consult to see the surgeon who will examine you and evaluate you for the actual surgical procedure. Psychosocial Evaluation – to be completed at the University of Washington Medical Center with a licensed psychiatrist or social worker. Important! You must continue your visits with a dietitian and PCP to complete the remaining steps of the DSHS requirement while you are enrolled in our program. Stage 3 (Authorization for Surgery) Following the process above, the Bariatric Team at UW Medicine’s Center for Bariatric Surgery will complete the necessary steps for approval and scheduling for surgery. This process includes submission of all of the Stage 2 records, including the surgeon’s recommendation, to DSHS for final review. DSHS will do a final evaluation of your records and make a final determination of approval for surgery. Once DSHS has made its determination, you will receive an official letter from DSHS to inform you of your approval or denial to Stage 3. If approved, you will need to immediately fax the UW Bariatric Team a copy of this approval letter to 206-598-6705 or 206-598-9470. Once we receive a copy of this letter, we can schedule your surgery. We hope that this letter and these guidelines listed explain the process for you and assist you in obtaining approval for bariatric surgery with DSHS insurance at UW Medicine’s Center for Bariatric Surgery. Please check out our website at www.uwbariatric.org for further information. We wish you the best in your efforts.
Sincerely,
The Bariatric Team
UW Medicine Center for Bariatric Surgery 4. Make sure you correctly understand specifically what your insurance requires. If something is foggy - get clarification in writing!!!
5. If you have a 6 month or year doctor supervised weight loss requirement make sure it is more than complete! My doctor just had my weight, blood pressure, height, and stated following diet, or still dieting. That wasn't enough! I was denied! They want it spelled out clearly such as: patient is following the Weigh****cher diet plan under my supervision - they want a specific plan you are following. They want behavior modification notes: such as patient is drinking at least 8 - 8 oz glasses of water a day, eating only lean proteins, no frying, limiting fats to......etc., Exercise - they want to know what you are doing and how much. Be specific and show improvement on exercise each month.
6. Most insurances want a letter from you stating your willingness to comply: List your past dieting attempts and failures, be specific with names of diets and dates. List what wls books you have read to learn from, list any support groups you have joined/are attending. List WLS on line groups you are a member of, list statistics about WLS and how it helps diabetes, sleep apnea, high blood pressure, etc. List statistics on how much longer people live after having wls. Let them know you are throughly informed and are not taking this surgery lightly.
7. State spefically why you want this surgery, how it will change your life, tell them about the vitamins, mineral, supplements you will have to take for the remainder of your life and tell them your source for purchasing them etc.
8. State any and all medical problems you have: diabetes, high blood pressure, sleep apnea, COPD, etc.
9. If you have seen any specialists - get a letter of support from them too. The more doctor's support letters you have makes it harder for insurance to say no.
{End Quote}
I really hope this helps.... I'm still trying to make it to stage 2. I'll know in 10 days I hope.
-Billie Jo
Found something else to simplify the DSHS guidelines...
{QUOTE}
The DSHS 3 Stage Process Simplified. You must be persistent and follow their guidelines, although vague, to the tee. I decided to share this information with you so that you wouldn't be as confused as I was! The first step is to have your doctor (I had my surgeon) apply for pre approval for the surgery. Your doctor must provide medical evidence that this procedure is medically necessary. (Things like Diabetes, Sleep Apnea, Hypertension, and Arthritis etc… are the things they look for.) This is stage 1. If the state finds it medically necessary that you have the surgery you will get a letter stating that you have been approved for stage 2. If you haven't done so, you need to find a surgeon who will accept DSHS. Your stage 2 approval letter should have a list of medical providers that will accept your medical coupon. Stage 2 is a 6 month trial period, so to speak. You will be required to see a dietician every month for 6 months as well as your doctor. You MUST lose 5% of your body weight. This is VERY important. Without this weight loss and the dietician reports they will deny you. In the 6 months where you are concentrating on losing that 5% you will also be required to complete a series of various tests. For me it was a sleep study, blood tests, EKG, pulmonary function test, x-rays, ultrasound, upper GI, and more. There were quite a few. These are just to make sure you are healthy enough to withstand the surgery. 6 months may sound like a long time, but let me tell you it will fly by! You will be so busy trying to jump through all the hoops that you will be praying for more time to complete them all! Once you have gotten all your "tasks" done, your surgeon will need to submit your medical files to the state for surgery approval. Your approval should come in the mail within the next 2-4 weeks! The key here is to not lose heart. These stages will actually help you in the long run. There is no doubt in my mind that this entire rat race has prepared me for what is to come. You may want to give up, but just remember, persistence will get you through this. If I can do it, so can you!
(kristine76)
{END QUOTE}
If you have any questions please feel free to ask. I'll try to help in the best way I can.
-Billie Jo
{QUOTE}
The DSHS 3 Stage Process Simplified. You must be persistent and follow their guidelines, although vague, to the tee. I decided to share this information with you so that you wouldn't be as confused as I was! The first step is to have your doctor (I had my surgeon) apply for pre approval for the surgery. Your doctor must provide medical evidence that this procedure is medically necessary. (Things like Diabetes, Sleep Apnea, Hypertension, and Arthritis etc… are the things they look for.) This is stage 1. If the state finds it medically necessary that you have the surgery you will get a letter stating that you have been approved for stage 2. If you haven't done so, you need to find a surgeon who will accept DSHS. Your stage 2 approval letter should have a list of medical providers that will accept your medical coupon. Stage 2 is a 6 month trial period, so to speak. You will be required to see a dietician every month for 6 months as well as your doctor. You MUST lose 5% of your body weight. This is VERY important. Without this weight loss and the dietician reports they will deny you. In the 6 months where you are concentrating on losing that 5% you will also be required to complete a series of various tests. For me it was a sleep study, blood tests, EKG, pulmonary function test, x-rays, ultrasound, upper GI, and more. There were quite a few. These are just to make sure you are healthy enough to withstand the surgery. 6 months may sound like a long time, but let me tell you it will fly by! You will be so busy trying to jump through all the hoops that you will be praying for more time to complete them all! Once you have gotten all your "tasks" done, your surgeon will need to submit your medical files to the state for surgery approval. Your approval should come in the mail within the next 2-4 weeks! The key here is to not lose heart. These stages will actually help you in the long run. There is no doubt in my mind that this entire rat race has prepared me for what is to come. You may want to give up, but just remember, persistence will get you through this. If I can do it, so can you!
(kristine76)
{END QUOTE}
If you have any questions please feel free to ask. I'll try to help in the best way I can.
-Billie Jo
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