Question:
Anyone insured by Kaiser? If so anyone have trouble getting approved?
I spoke to someone who had gbp through kaiser two years ago, and I know things have changed since then. I was just wondering if anyone had it recently through Kaiser, and if there was trouble getting approved. — rm R. (posted on January 1, 2003)
December 31, 2002
I have Kaiser and started the log road to wls on 12/19/02.
The 1st thing you need to do is see your PCP. Kaiser now has a worksheet
for PCP's to follow that will help them know how to help you. My PCP
verified my BMI (the chart she had only went up to 40 and on the worksheet
it said I had to be over a 40 BMI. I am at 47.) She then took a brief
medical history i.e. past surgeries, co-morbs, possible co-morbs, weight
loss history etc.... At that point she told me she would send a referral to
the Nutrition Services Department, Psychiatry Department and gave me a form
so I could set up my own appointment for a sleep study. She also told me I
would need to enroll in a 1-year weight management program but that it did
not have to be at Kaiser although she did recommend their program.
Well that day I went home and made my sleep study appointment for 02/05/03.
That was the 1st appointment they had available. I am on the cancellation
list to see if anything sooner pops up. The following day I called
Nutrition services to verify that they had my referral and set an
appointment for 02/03/03. Again the 1st day available. I them called
Psychiatry where I was informed that they did have my referral but that
they will not even set an appointment until after they have the report from
Nutrition Services. I also set an appointment for "Introduction to
Weight Management" which is an orientation Kaiser requires before you
are allowed to participate in the weight management program. That is set
for 01/07/03. I was shocked I could get in that soon.
The one thing I have seen other Kaiser members post is that the weight
management program is "recommended" but not required. When I meet
with my PCP again on 02/11/03 I am going to present her with a letter
detailing my life long battle with my weight, co-morbs and weight loss/gain
history. I am hopeing I can convince her to send it in to the approval
committee along with all my results from my other appointments without
needing to complete the weight management classes. I am still going to
start them to show my commitment to the surgery.
From all that I have seen and heard Kaiser is a long hard road but if you
are dedicated, persistent and at times pushy it gets results. Good
Luck!!!!!!!!!!!!!!
— mlovesh
January 1, 2003
Just like any other insurance company or HMO, the rules for how to get
approved through Kaiser can vary from one employer to another and from one
state to another. I have seen posts from people who had to go through a 6
month supervised weight reduction program and had other hoops to jump
through. Many of these had to wait a year between referral and surgery. I
have seen other posts from Kaiser patients who were referred and had
surgery within 6 months. Get the details from your employee handbook,
which you should be able to get from your employer's HR department. Or
call their patient services dept and ask what you have to do.
— garw
January 1, 2003
Hello, I am now following the guidelines that Kaiser has set up. I believe
that these guidelines are for all of Kaiser and not just for my insurance
plan. They require that you first of all meet the NIH criteria. After
that you need to have a history of weight loss attempts with appropriate
exercise for your abilities and they didn't ask for indepth attempts from
me, I just stated it to them in my letters. They also want you to have a
psychiatric evaluation and be cleared for surgery by the psychiatrist. The
biggest part is that they want you to have 6 months of evaluations and
consults with their nutritionist. I had thought that they wanted me to try
to diet again but that wasn't the case. They want you to go to see the
nutritionist because they have found that people do better after their
surgeries once they have been "trained" by the nutritionist. I
had my first consult this past Monday and she gave me info on the surgery
and wants me to keep a journal of food and exercise for at least a week or
two for the next time I see her this month. She told me that later
sessions will be about eating right after surgery including portions and
supplements. I hope this helps....
— Morna B.
January 1, 2003
Also, I forgot to add that I had to take a "Nutrition for Weight
Loss" class provided by Kaiser.
— Morna B.
January 1, 2003
Other than the 6 month delay this seems like a pretty good way to go about
WLS. The classes and working with the nutritionist is their way of knowing
that you truly know what you are getting into. I'm sure it will help with
dealing with the changes afte surgery. I would be upset about the delay
but if I step back and am objective, more insurance companies should take
this approach in my opinion.
— zoedogcbr
January 1, 2003
I was approved through Kaiser in 2 days. I do feel the only reason I was
approved that quick was because have out of network benefits. I will have
to pay 20% of my surgeon's fee. The hospital was in network so that will be
covered. We just got Kaiser as of Dec. 1st and I know if you have to stay
in network, their guidelines are very strict. Don't give up, call member
services and ask for their explanation of benefits regarding gastric bypass
surgery. Get it all in writing. I had Fidelity before that and did not do
that and got my letter of medical neccesity from PCP, saw the nutritionis,
saw the pyscho and waited 3 months for a consult with surgeon. Then after
six months of waiting, we submit for approval and I find out they want a
supervised diet for 6 months straight within the last year. I could have
been doing that while I was waiting. So frustrating! Get it all in writing
and then get cracking on what you need to do. Good Luck. :-)
— donna B.
January 1, 2003
I live in the DC area and have Kaiser Mid-Atlantic...while they requrire a
lot of testing and hoop jumping, it doesn't seem to be too much more than
other ins. cos. All in all, it took me about three months from the time I
made the decision to have WLS until I actually had it done. All I can say
though, is that I am glad I don't have Kaiser in one of the Western states,
like CA or CO. I would NOT have had the patience to do all the nutritional
counseling classes, etc. I think making people wait so long to find out if
they are even approved or not borders on cruel...
— rebeccamayhew
January 4, 2003
I went to Kaiser 3 years ago and was turned down flat (5'4" - 292
lbs), my only co-morbid was osteo-arthritis in the knees. They asked me to
try Optifast, which I did and failed. then in late summer this year
(August-September) I tried again. My PCP didn't like the risks, but I
wrote him a letter telling him about my struggles/Optifast/desire to go the
surgery route and needed his support or help to find a more sympathetic
PCP. He supported me, was approved in less than a month. They did tell me
though that in San Diego, they were now approving differently than my first
try and I was the first one to be sent to LA for the approval process. I
have found Kaiser is taking a more liberal stance on GB, but since my
surgery have heard that they are making everyone first go through the
Positive Choice center (their weight loss program - Optifast). I also
think each state/location is different - but, I refused to give up, Good
Luck to you!
— Bonnie S.
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