DS and Kaiser (Southern CA)

I am finding your post confusing, and I'm not sure how to answer some of your questions.

I have never heard of Kaiser, NorCal or SoCal, saying they cover the DS.  This may be a new thing where they SAY they cover it, for legal reasons, but then NOBODY will qualify according to Belzberg (who is, after all, PAID by Kaiser).  In other words, I doubt very much you will EVER get a Kaiser surgeon, including Belzberg, to say the DS is best for you.  We DSers call this practice "bait-and-don't-swtich."

I don't understand what you mean about having an option to meet directly with the surgeon without doing the Options classes.  Do you mean you can meet with the surgeon to see if you SHOULD have surgery at all, or to discuss which one, and then you have to go back and take the Options classes anyway?  If you have been told to sign up for or that you have to take the Options classes, you can file the grievance with the DMHC to ask them to order Kaiser to waive the requirement.  How that affects your interactions with the Kaiser surgeon (Belzberg? someone else?) is something I don't know.

Keshishian has an office in Glendale.  You are NOT going to get a LOMN for a DS from anyone but him, or Crookes at USC (although he is not a given on these things) - as I said above.

Sorry if I sounded confusing. Earlier in the week I called Kaiser Member Services and they told me that they only cover the RNY and the Lap Band. But later in the week I was able to speak to someone who actually read off of a screen that they cover basically ALL types of bariatric surgery. The list included the DS. YOu may be right that they have to tell me that they cover it--to protect themselves for legal reasons. In any case, for the record, they cover it. 

Next, the way the Kaiser Options program was presented to me was that I go to Orientation, at Orientation they give a run down on the types of procedures they do and then explain the classes. I was told by the director at the Woodland Hills branch that they will give me the option of meeting directly with the surgeon and bypassing classes (no pun inteded) thus giving my spot up in class to someone else. We are not permitted to meet with a sugeon durring the class process. The director said that 99.9% of people who meet with the surgeon before classes get turned down. She also said (to discourage me) that if I meet with the surgeon, instead of starting classes in July, I'll have to wait a couple of months to begin. But if you're correct that the classes have nothing to do with the DS, then I'll forgo my spot and then possibly meet with the surgeon who performs the DS. The meeting with the surgeon is soly to have them tell me whether or not he/she thinks I should be able to schedule the surgery. That's when they send me away to take classes.

So I may just go ahead with the DMHC grievance form--regardless of what that does with my relationship to my surgeon.

Sheri

Sounds like a plan - BUT!  Belzberg is in the Harbor City facility.  Will they refer you down there from the west Valley?

I would challenge them to state ON THE RECORD what requirements they have to qualify for the DS.  I'm guessing they'll say BMI >60.

I'm not worried about Belzberg being in Harbor City--My guess is that won't be a problem. From my recent experience, it appears I can see anyone in the Southern CA area (actually also in the Northern Ca area too since we're interregional members). But I am curious about what you had to say about them saying the BMI would have to be >60. So you're saying they'll say that's the requirement? Is that the most likekly basis of their regection? How ridiculous! I'm over a hundred pounds over weight and my BMI is only 41.6. So I'm getting from you that I need to have the doctor put it in writing that I'm being regected due to xy or z reason. Do you think the BMI will be an issue with the outside surgeon?

Keshishian would NOT see your BMI as a problem.  But I'm guessing that - to the extent Kaiser is willing to say that they "cover" the DS, that THEY have a policy which limits it to only the most extreme cases.  The DMHC will almost without a doubt overrule that - but it will require appealing and filing an IMR.

But maybe they won't - I just wouldn't take that bet.  Nevertheless, NorCal Kaiser has been changing their tune just a bit - they have recently sent a couple of people directly to Rabkin with only ONE internal appeal, and without requiring the patients to appeal to the DMHC.  But they both had VERY high BMIs.

So then, before I begin this battle (because it seems like that's what I am facing here) do you think I'll have a leg to stand on with getting the DS with a BMI of 41.6?

I have diabetes, a long history of diabetes in my family (my mom and both of her sibblings, my brother, 3 of my grand parents, and their parents as well), history of stomach cancer, the need to take NSAIDS for back pain (2 disc bulges), and the PCOS.  I want to fight a battle that I have some hope of winning.

I also worried that since i take antidepressants and a mood stabilizer (have done this for years and am in great mental health) that this will also make it hard for me to convince the system to give me the DS. But I must say that since doing all of my research, I have no question that the DS seems superior to the other forms of bariatric surgery--therefore I want to fight for it.

Do you know of any others here who have gotten the DS who have a BMI anywhere near mine?

The DMHC almost always follows the NIH and Medicare rules - the DS is appropriate for anyone who qualifies for bariatric surgery.  LOTS of people have gotten the DS with lower BMIs, even between 35-39, with a significant comorbidity such as diabetes, sleep apnea, hypercholesterolemia and hypertension.

That's good to hear. One last question (today): If I file a grievance with the DMHC do I need to have any written evidence that Kaiser has told me to take the classes prior to surgery? At this point all I have is my paperwork for orientation. If they need something in writing, then perhaps I should wait until I see the surgeon and let him regect me--then get written proof, and proceed with the grievance.

I don't really know - it certainly would be conclusive, but the DMHC knows full well that SoCal Kaiser always tells their patients to do the Options classes.  Ask the DMHC person who is taking your complaint.

I will do as you suggested. I have just submitted my first grievance to Kaiser asking for them to wave the classes and weight loss requirement and I sited the DMHC report. I did not mention the DS since I want first to be approved for the surgery--then get into specifics. Monday, I'll call the DMHC and see if they can offer any insight  on where to go from here with the grievance with them--regarding written proof, etc. Thanks.