Our decision: We agree with you.

"This means that Kaiser must approve your request for BPD with DS." 

Ladies and gentlemen of the DS board, this is the official word from Maximus Federal Services--I got the letter today!

I know I'm not a frequent poster, so some of you may not know my story.  I'll try to keep it short.

In early 2007 I requested WLS from my Kaiser PCP.  She sent in the referral, I was approved right away in May, 2007, and was signed up for the Options classes.  It took 5 months to get into the Options classes because of the waiting list, and six more months to complete the classes.  After I was approved for WLS, I began my quest for the DS.  Again, it took months before I was able to talk to the Kaiser surgeon about the DS.  The Kaiser surgeon offered to give me the VSG, but would not approve me for the DS.  I filed two grievances with Kaiser, was denied both times, and my case (appeal) was then sent to DMHC for an Independent Medical Review.  In my appeal, I asked for the DS, and I asked to be excused from the remaining Options classes.

DMHC only partially overturned my appeal.  The DMHC ruling excused me from completing the Options classes, and gave Kaiser permission to give me the VSG, but not the full DS because the DMHC didn't believe that the full DS was medically indicated at the time.  Mind you, at the time of the DMHC ruling I had a BMI of 51.7, and several comorbidities, yet DMHC still denied me the DS.  The ruling for my appeal did not make any sense.  (My DMHC appeal number is MN08-7582 for those who may be interested.) 

In my appeal, the DMHC stipulated that there was a possibility of completing the DS under the following conditions:  "If weight loss is not adequate (< 40% of excess body weight) and/or comorbidities do not improve, a staged conversion to BPD/DS is possible and would be indicated if treatment with NSAIDs continues."     

So, in March, 2008, I had the VSG.  In the sixth month after surgery, my weight loss completely stopped.  In February, 2009, I asked Kaiser to complete the DS because I still had a BMI of 40, I still had all the comorbidities that I started out with, and I would always have the need to take NSAIDS for the rest of my life because of osteoarthritis.  In my case, the VSG was just not powerful enough to get me to a normal BMI and get rid of my comorbidities.

Kaiser stalled and put up as many road blocks as they could to keep me from getting the DS (I could write a book!).  So, again, I went through the grievance process with Kaiser, was denied again, and my appeal was automatically sent to Maximus Federal Services. 

This time, Maximus decided in my favor!  Yes, my friends, after two years and two appeals, I am finally getting my DS!  Finally.  Somebody pinch me! 

This has been a long two years, and I couldn't have gotten through it without the help of Diana Cox and Larra.  They have guided me, held me up, encouraged me, and put up with my highs, lows, and even my anger at times!  Larra and Diana were with me through every grievance and appeal, every step of the way, and they had so much patience with me.  Even though this has been a long, difficult, two years, I have learned so much from these two professional ladies.  Because of this experience over the past two years, I have gained more confidence in myself, and feel much stronger than I did when this whole process began.   I can't give enough praise to these two women who give of themselves so generously.  Thank you, Diana and Larra!  You're the best!

I'll keep you all updated on my progress!

Congratulations my friend! I am so happy for you. All the hard work has paid off... Love ya

Thank you, sweet friend!  I should include you in with Larra and Diana because you've been holding me up IRL.  You poor thing!  You've been through a lot! 

Congrats!  I am SOOOOO very happy for you!

Thank you, Tracie!  I still need pinching!

I am thrilled for you. I absolutely love to hear about it each time Kaiser gets overturned. I am angry that you had to wait so long to get the surgery that you needed to be healthy. I have been in a similar position and didn't know how "easy" the appeal process would be for me to get Kaiser to pay for the DS. I am still waiting to hear back from Maximus or the DMHC. I should hear any day now.
Keep us updated on your progress and surgery date.

Ahhh, Gail, the waiting is so hard!  Like I said earlier, mine was a very strange ruling by the DMHC.  I believe my ruling was the only "partial" in 2008--all the rest were overturned.  You're going to win!

I'll be looking for your victory post!

  Here's your pinch!  So nice to hear from you, Terry, and even nicer that you have such good news.  I am soooo happy for you!  -Jenny

I needed that pinch!  In fact, I could use a few more!  It still seems so unreal to me.

Thank you, Jenny!

 Congratulations Terry.  I'm so happy for you that the DMHC finally did the right thing and made Kaiser pay for you to have the DS. Weird that they would make you have two surgeries instead of one. Hopefully you'll know who you are referred to soon and will be getting a date for your revision. I know you'll be a great DSer.  Thank goodness for Diana and Larra without them many of us would never have been able to fight the evil insurance companies.