Kaiser updates...

May 09, 2009

After researching quite a bit & reading things here on OH, I believe DS will give me (and most others) the best quality of life.

3/05/09 - Chris (Crazeru ) emailed me a plan of action 

3/07/09 - First grievance to be put into Bariatric's mailed...

3/27/09 - Dr referred me to bariatrics, in the letter that was sent it says to wait a few weeks with information & scheduling options for the Bariatric Surgery Program ( I have since switched my PCP!!)

3/28/09 - Called to see if I could get info sooner. Spent a lot of time being transferred around, then finally got someone at bariatrics that scheduled me for their next info session!

4/23/09 - Attended Bariatric Info Session (I made it a point to ask if DS was covered & if Options was mandatory, they said no for DS & yes for Options, now I can file my first grievance about the Options classes!!) The classes take 5 months to get into & then you go to another 5 months of classes, can you say STALL TACTIC??!!

4/24/09 - Sent in a grievance to opt out of the Options classes based on the fact that DS is not discussed during these classes (I asked at the info session & I was told it wasn't)

5/1/09 to 5/5/09 - From what I understand, you need to have a surgeon (that Kaiser sends you to) tell you no to DS before you can file a grievance to get DS. In the Bariatrics Program you do not get to see a surgeon until you finish the Options classes. Nice huh?? I called the people at Health Education to see if I could see a surgeon sooner because I was grieving against Options. I was told by them that my PCP had to send a referral for me saying I could see a surgeon before completing Options. My PCP did that & they made an appointment for me to see the Director of the Bariatrics Program who apparently is the only one who can authorize me to see a surgeon. Ready for the best part? The appointment is about 7 weeks away!

5/2/09 - I received a letter from Kaiser stating that they have received my "request for Health Plan coverage for a Duodenal Switch procedure" and that I had until the 7th to get them any additional info (appeal papers),  WTF???? My grievance was to opt out of the Options program because I would be requesting DS, not that I was requesting DS. Luckily I was already working with Dr. Larra & Diana on my appeal letter so I was able to get it sent in on time.

5/7/09 - Faxed in my "additional information" to Kaiser & formally requested to opt out of Options, a DS and a referral to a surgeon who does DS. Now they have 15 days to get me a response! I'm nervous to see what they'll come up with. We shall see!

5/12/09 I got a letter from Kaiser dated 5/8/09 saying no to bypassing Options and no to DS. Here's their reason:  

Your request for Health Plan coverage for a Duodenal Switch procedure and to bypass the Option Program has been denied. Physician review has determined that there is no medical indication to bypass the options program, since this is an important component of treating morbid obesity. Following the Options program, the Bariatric Surgeon will make recommendations regarding appropriate surgery. As a result, Health Plan has denied your requests.

 Your request is being automatically referred to our Regional Appeals Committee for additional review. We will resolve your grievance within thirty (30) days from the initial date of our receipt of your grievance.

 5/19/09 Called to get my Kaiser medical records.

 5/27/09 I got my second & final denial dated 5/22/09, here's their reason:

This denial was based in the following reason(s):

Your request for Health Plan coverage for a Duodenal Switch procedure and to bypass the Option Program has been denied. Regional Appeals Committee has determined that a Duodenal Switch procedure is not medically indicated. In addition there is insufficient information to support that you bypass the Option program, this program is designed to assist our members make an educated decision regarding this type of surgery and lifestyle post operative changes for best surgical outcome. The Regional Appeals Committee recommends that you consult with one of our Surgeons to discuss what surgical options are available to you. As a result Health Plan has denied your requests.  

Now it's time to get ready for the DMHC!!  

5/27/09 Tried to make an appointment with Dr. K to get a letter stating that the DS is medically indicated for me.  

5/31/09 I faxed my request to opt out of Option to the DMHC.  

6/1/09 I called the DMHC to make sure they received it, they did.  

6/1/09 Dr.K's office called & said he would see me June 15th for a consultation. I have to pay out of pocket for this. It's $285. From what I understand you may get reimbursed for this if you win your IMR.  

This is where I messed up & wasted 18 days. I should have already had an appointment done or at the very least made one for just after I would have received my final denial.

6/6/09 Received my Kaiser records.

6/11/09 DMHC called & we had a bit of a mix up with the Option part. A few days later it was finally figured out that I filed for Options as an IMR & not a grievance as I should have. Got that figured out & it should be in the right place.

6/15/09 My meeting with Dr. K was supposed to be this day & I showed up about a half an hour early only for the door to still be locked. I called about 5 minutes after my appointment time because the door was still locked. It turns out my appointment was in Delano CA & not Glendale CA, where I was. Make sure if you go with Dr.K you go to the right city! I rescheduled for 6/18/09.

6/18/09 I met with Dr. K. I have a smile on my face while typing this. I LOVE that man! He was so kind & genuine. I had my cousin with me & she got to listen to all the benefits of DS. Now I have someone who is completely for me having this surgery! I have family support, but none of them actually want me to have the surgery. He agreed that the DS would be good for me & he was willing to write me a LOMN.

6/22/09 I met with the Head of Bariatrics for Kaiser and the Dr. that teaches the Option classes at Kaiser. PM me if you want more details about the meeting or either of the Dr's.

6/25/09 Dr.K's nutritionist called, asked me a lot of questions & said she agreed to having the letter written for me. 

6/28/09 I finished my letter for DS today. As soon as I have my LOMN I will mail it all to the DMHC for an IMR.

7/2/09 Received Dr. K's consult report.

7/3/09 Mailed everything off to the DMHC. Now, I get to sit back & wait. It should be 30-45 days to get an answer.

7/20/09 I was wrong. The wait is 30-45 days from the day that your case is accepted as an IMR. Mine was accepted last Friday & got sent in for the IMR today. So, I get to wait even longer.

7/29/09 I was told it was accepted but I was called again today & told that now it's finally been sent out for an IMR. So, hopefully I'm being told the truth this time & it really will be 30-45 from TODAY!! We'll see.

8/26/09 I got a call today from my case worker & what do you know? I WON! Kaiser will now be required to pay for yet another DS! I still don't know anything about the Option classes. I should get more details in the next few days.

I am very lucky in the fact that if I lose my IMR I can always start again with a PPO in January. Many people aren't this lucky, get it right the first time.



Something that needs to be mentioned is that all along I have been working with DianaCox & larra. These are two truly amazing women who have given me more of their time & expertise than I (or anyone else) deserve. So much more than any other person would.  If I win this thing, it will be completely because of them. I don't think people on here really realize just how much these two do to help you when they can and all for free. These ladies are really something special. 

I should also mention that I am only here because of Pay-It-Forward & surgery wars. Diana, thank you for your signature & Chris, thank you for my plan of action! Surgery wars save people from mediocre surgeries!!


 

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