Kaiser's preop requirements.

Hi all.  I'm assisting my sis in wading through Kaiser's requirements .  She's been through the orientation ;is 50 yrs old, has a BMI of 50 with co-morbidities of painful back, feet, snoring, acid reflux, family history of cardiac disease/heart attacks,hypertension, shortness of breath on exertion.  She has been "prequalified"for bariatric surgery by Kaiser based on her BMI alone.  I presume she is only "prequalified" because of Kaiser's requirement of the supervised diet documentation and the Options classes??  Once those requirements are accomplished is a person THEN referred for a psych & surgical consult.  I'm trying to figure out Kaiser's system of hoops so as to not waste a minute of my sisters life.  BTW we live in San Diego. Have any of you greived the preop diet requirement with Kaiser and then ultimately gone onto request a Independant Medical Review with CA Dept. Of Managed Care?  I have read on their website that they have found no benefit in this requirement or any literature by any authority that mandated weightloss once a person has been identified as a candidate for bariatric surgery, is indicated.

Thank you for your help!
Brenda

Part of the confusion with Kaiser's requirements is that Kaiser in Northern CA and Southern CA are different health plans, and their respective bariatric surgery programs have different requirements. I know more about Northern CA but will help as much as I can.

    In Southern CA they will ask about prior weight loss efforts but I don't think they require a 6 month "supervised" diet as many other insurers do. If your sister can list her prior efforts, such as Weigh****chers, Jenny Craig, Optifast, Nutrisystem, fenphen, etc etc. hopefully that will be sufficient. Perhaps people who have been through the So Cal Kaiser program can clarify this.
   Now, the Options Classes...it is my understanding that people can file a grievance for this. She would have to go through Kaiser's internal appeals, which takes 30 days, and where she will almost certainly lose, and then file with the DMHC, where she stands a good chance of winning. This won't happen overnight, obviously, but given that peole are waiting several months just to START the options classes and then the classes themselves take about 6 months, it would be much quicker than the classes.  And since she can't get into the classes right away anyway I don't see what she has to lose by trying.
    Once she gets past that barrier, the next big question is what operation to have. If she wants rny or lap band, she is all set. But if she wants the DS she will need to grieve for that as well. She would first need to get a denial from Kaiser, then go through the internal appeals, then on to the DMHC. The DMHC is overturning almost all denials of the DS, and has for several years now, and I think esp with her bmi being 50 her chances are excellent.
     If your sister is interested in the DS, there are people on the DS forum who can help her with her appeals. Just let me know.

 

Larra

 

Hi Larra. 

Kaiser SoCal hands out a booklet to bariatric surgery candidates that reads---In order to comply with National Institute for Health and Kaiser Permanente standards, Kaiser Permanente members considering bariatric surgery are required to complete a supervised  and documented 6 month weight management program---; this in addition to the Options classes. 

We will grieve through Kaiser for sure but  I'm wary that since my sis is only prequalified for surgery that Kaiser will pull some shenanigans based on that alone.  We shall see. Thanks  so much for your reply!

Hi Laura, I went through Kaiser and I didn't do the 6 month supervised diet. I went to the orientation and then the 24 week classes. They then referred me for my appointments with an internist, phychiatrist and surgeon (all in one day). I had my surgery at Scripps in San Diego. Good luck to your sister on her weightloss journey. =)

~Katt~

Hi Katt.  It surprizes me you did'nt have to go through the diet. Did you have documentation of a past surpervised diet or did you just have to write down what diets you've tried in the past? I'm glad you did'nt have to go through the rigamaroll of diet before surgery.  Did you find the classes particularly helpful to you postop?

Thanks!
Brenda

All I did was fill out the packet of paperwork and submit it. I've never been on Jenny Craig, Weigh****chers, Adkins or anything else. I did list that I had been on a modified diabetic diet (1200-1500cals/day) per my PCP and all the OTC diet pills. That seemed sufficient for them.

As the good Doctor, Laura mentioned, this should not be a requirement with So CA Kiaiser. Although, DMHC seems to have removed this from their site, I know Northern CA Kaiser patients have quite successfully appealed this nonsense easily in the past using this former DMHC document.

The Department of Managed Health Care (DMHC) requested that MAXIMUS CHDR perform a
physician review of whether generally accepted medical practice in the United States and medical
and scientific evidence supports the proposition that prior to otherwise medically necessary
bariatric surgery, candidates should lose 10% of their weight.
 
MAXIMUS CHDR’s review was completed by a board certified, actively practicing general
surgeon who is licensed to practice in California who specializes in bariatric surgery in
conjunction with MAXIMUS CHDR staff. In addition, the results of this review were discussed
with two other surgeons specializing in bariatric surgery – one who practices in New York State
and another who practices in Georgia. The result of these discussions demonstrated that although
there are bariatric surgeons *****commend weight loss for certain patients prior to surgery,
there is no scientific data demonstrating that such weight loss is necessary or beneficial.  
 
As part of the request DMHC provided a number of discussion points, which are addressed
throughout the following narrative. In addition, the citations to the literature and other works
referenced below can be found on the works cited page following the narrative.
 
SUMMARY CONCLUSION
 
There is no literature presented by any authority that mandated weight loss, once a patient has
been identified as a candidate for bariatric surgery, is indicated. There is a mixture of results that
question whether weight or truncal obesity is a risk factor for complications after bariatric
surgery. The more analytic studies have not found that body mass index (BMI) or total weight is
an independent risk factor for complications or death from bariatric surgery.
 
No institution that has recently published data on bariatric surgery describes a protocol requiring
weight loss between identification of the need for surgery and the surgery. Many institutions in
California have published results of surgery with particular focus on factors that contribute to
morbidity and mortality. No paper from a California institution mentions mandated weight loss
before bariatric surgery. Nor does any literature regarding the treatment for the morbidly obese
recommend continued weight loss during the period between identification of the need for
bariatric surgery and the surgery.
 
Mandated weight loss prior to indicated bariatric surgery is without evidence-based support.  
Mandated weight loss prior to indicated bariatric surgery leaves the patient at increased risk from
the patient’s comorbidities. Mandated weight loss prior to indicated bariatric surgery is not
medically necessary. Mandated weight loss prior to indicated bariatric surgery would be deviant
from the standard of care practiced in the United States and other published countries. The risks
of delaying bariatric surgery, while not entirely known in the short-term, are real and can be
measured. Any potential value of losing weight prior to bariatric surgery is theoretical and not
supported by any data. An experimental study including fully informed consent to determine if
there were a reduction in risks or other benefit from mandated weight loss prior to bariatric
surgery is indicated.  
 
The National Institutes of Health (NIH) published a Consensus Paper regarding “Gastrointestinal
Surgery for Severe Obesity" in 1991. These guidelines were updated in 1996. Other guidelines
for the treatment of the morbidly obese include the National Institutes of Health, National Heart,
Lung and Blood Institute, Mun, Fisher, and the American Gastroenterological Society. These
guidelines provide consensus information regarding the care of the morbidly obese, including
surgery. Many steps of care are mentioned and cited. There is neither mention nor citation that
once a person is identified as meeting all criteria for surgery to treat severe obesity that one
should lose a mandatory amount of weight or a percent of one’s body weight to reduce surgical
risk or to improve outcome.
 
A number of guidelines, peer-reviewed meta-analyses, and other publications in the peer-
reviewed literature describe the rationale for considering surgical treatment of obesity. Such
surgery will, in this paper, be referred to as “bariatric surgery." The American Society of Bariatric
Surgery updated their guideline in November 2001. Kolanowski provided a literature review and
guidelines for care in 1997 from the Belgium and European viewpoint. Other reviews have been
provided by Balsiger, Sugarman, Brolin, Garza, Fobi, and Stocker. The National Guideline
Clearinghouse includes no guidelines. The Cochrane Collaborative database contains meta-
analysis and reviews of a number of topics, including “Surgery for Morbid Obesity." These
guidelines provide consensus information regarding what is appropriate care for a patient with
morbid obesity. Many steps of care are mentioned and cited. There is neither mention nor citation
that once a person is identified as meeting all criteria for surgery to treat severe obesity that one
should lose a mandatory amount of weight or a percent of one’s body weight to reduce surgical
risk or to improve outcome.
 
Besides peer-reviewed journal articles, Hayes, Inc. has published technology assessments
regarding bariatric surgery, as have PacifiCare, and Blue Shield of California. These guidelines
provide consensus information regarding the care of the morbidly obese, including surgery. Many
steps of care are mentioned and cited. There is neither mention nor citation that once a person is
identified as meeting all criteria for surgery to treat severe obesity that one should lose a
mandatory amount of weight or a percent of one’s body weight to reduce surgical risk or to
improve outcome.
 
The referenced articles, as exemplified by the NIH, recommend a multi-disciplinary team to
evaluate and assist the morbidly obese patient, in the hopes of avoiding bariatric surgery through
either finding a reversible etiology or through sustained support. The guidelines agree that once
supervised weight loss has failed, the patient is appropriate for surgery if mentally stable and
there are no other etiologic factors. No guideline mentions, cites, or recommends mandated
weight loss prior to bariatric surgery. Thus, it is not that the guidelines are silent on the matter of
preoperative care, but that they do not recommend any weight loss prior to bariatric surgery once
the patient is deemed as meeting the criteria as one who would benefit from the surgery.  
 
A literature search through Pub-Med and the already cited articles identified a number of articles
that included some comment regarding protocols for bariatric surgery. No article referenced
discusses mandated weight loss after identifying the need for bariatric surgery. Similarly, review
of the literature describing the protocols and results of institutions in California, the United States,
and throughout the world do not include a single reference to mandated weight loss prior to

bariatric surgery once the patient meets the criteria for benefit from bariatric surgery.  These
include Husemann from Germany, Moose from Pasadena, Argeaga from Los Angeles, and Oliak
from New Jersey.
 
COMPLICATIONS OF BARIATRIC SURGERY
 
A literature search through Pub-Med and the already cited articles identified a number of articles
that provide data relative to the complications of bariatric surgery (e.g., Balsiger, Colquitt,
Kolanowski, Husemann, Moose, Dindo, Arteaga, Klietz, Liu, and Pope). A general range of risk
is reported consensually, with a decreasing risk during the past two decades. No article mentions
mandated weight loss before surgery for patients who meet the criteria for bariatric surgery.
 
Factors Predictive of Complications
 
The first prospective evaluation of the risks in general surgery from obesity was reported in
Lancet in 2003. As the authors stated:
 
Obese patients are generally believed to be at a higher risk for surgery than  
those who are not obese, although convincing data are lacking. The morbidity
rates in patients who were obese compared with those who were not were much
the same, with the exception of an increased incidence of wound infections after
open surgery in patients who were obese…Incidence of complications did not
differ between patients who were mildly obese, severely obese, and non-obese.
 
The interpretation of their study is stated as, “Obesity alone is not a risk factor for postoperative
complications. The regressive attitude towards general surgery in obese patients is no longer
justified."
 
Analysis of complications of bariatric surgery reveals a mixed, but revealing definition of those
factors that contribute to the development of complications from surgery. Oliak reports mortality
is higher in the super-obese (BMI greater than 60) but that there is not a significantly greater risk
of complications. Blouw performed a retrospective chart review of patients undergoing bypass
surgery to determine the rate of respiratory failure. Blouw compared those with BMIs less than 43
to those with BMIs more than 43. The higher BMI group had a higher, but not statistically
greater, rate of respiratory failure. No other variables were measured to determine if BMI was a
true independent variable.
 
Cooney studied cost outliers for bariatric surgery – those patients who cost more than was typical.  
The factors that were predictive of being a cost outlier were severe medical comorbidities
(especially diabetes mellitus and sleep apnea).
 
Fernandez performed multivariate analysis of factors related to leak after bariatric surgery and to
deaths. It was reported that, “The data suggests that older, heavier male patients with multiple
comorbid conditions are at increased risk for leak and mortality."
 
Sapala performed a retrospective analysis of 24 years of bariatric surgery and the risk of
pulmonary embolism. Inferior vena cava filters are one treatment to prevent or ameliorate
pulmonary emboli. Sapala found that a combination of risk factors, specifically, venous stasis
disease and BMI > 60, and truncal obesity identified a high-risk cohort of patients who should be
strongly considered for pre-operative placement of inferior vena cava filters.
 
Livingston performed univariate analysis on ten potential risk factors for bariatric surgery
complications. Univariate analysis revealed that male gender and weight were predictive of
severe, life-threatening adverse outcomes. Multistep logistic regression yielded only male gender
as a risk factor.  This group analyzed more factors than other groups, and performed multistep
logistic regression – that demonstrated that only gender was an independent risk factor.
 
Perugini used an inception cohort to attempt to identify factors predictive of bariatric surgery
complications. Multivariate analysis by stepwise logistic regression identified surgeon
experience, sleep apnea, and hypertension as predictors of complications. Neither BMI nor
truncal obesity were found to be predictive of complications in this inception cohort study.   
 
Courcoulas explored the volume-outcome relationship for gastric bypass surgery. The
Pennsylvania state discharge database was utilized to identify 4685 cases of gastric bypass
surgery for obesity between 1999 and 2001. A significant risk-adjusted relationship between
surgeon volume and adverse outcome was revealed with the same trend observed for deaths.
 
Schwartz examined a database of primary bariatric surgeries to look for preoperative
determinants of postoperative complications. This retrospective study found complications did
not correlate with any preoperative parameter measured.
 
Liu at UCLA, used the California inpatient discharge database. All gastric bypass operations from
1996 to 2000 were identified. Demographic, comorbidity, complication, and volume data were
obtained. Liu found that in California during those years complications were more likely in men
and in patients with comorbidities. Furthermore, when examining the effect of volume, patients at
very low (less than 50) and low (50-99) volume hospitals were much more likely to have
complications compared to patients at high-volume hospitals, even after controlling for
differences in case-mix. Liu concluded, “This study identifies three independent predictors of
complications: gender, comorbidity and hospital volume."
 
Iglezias and others present evidence that rapid weight loss may increase the risk of cholelithiasis.  
Prolonged hospital stay, fasting, and other conditions are known to increase the risk of
cholelithiasis.  Thus, there is some concern in the literature that rapid weight loss, possibly
interpreted to include mandated weight loss so that one could receive bariatric surgery, has
complications.
 
In the Swedish Obese Subjects (SOS) study Torgerson presented data demonstrating that surgical
subjects showed a definitive decrease in hypertension and diabetes while such decrease was not
evident in the non-surgical group.
 
 
pulmonary emboli. Sapala found that a combination of risk factors, specifically, venous stasis
disease and BMI > 60, and truncal obesity identified a high-risk cohort of patients who should be
strongly considered for pre-operative placement of inferior vena cava filters.
 
Livingston performed univariate analysis on ten potential risk factors for bariatric surgery
complications. Univariate analysis revealed that male gender and weight were predictive of
severe, life-threatening adverse outcomes. Multistep logistic regression yielded only male gender
as a risk factor.  This group analyzed more factors than other groups, and performed multistep
logistic regression – that demonstrated that only gender was an independent risk factor.
 
Perugini used an inception cohort to attempt to identify factors predictive of bariatric surgery
complications. Multivariate analysis by stepwise logistic regression identified surgeon
experience, sleep apnea, and hypertension as predictors of complications. Neither BMI nor
truncal obesity were found to be predictive of complications in this inception cohort study.   
 
Courcoulas explored the volume-outcome relationship for gastric bypass surgery. The
Pennsylvania state discharge database was utilized to identify 4685 cases of gastric bypass
surgery for obesity between 1999 and 2001. A significant risk-adjusted relationship between
surgeon volume and adverse outcome was revealed with the same trend observed for deaths.
 
Schwartz examined a database of primary bariatric surgeries to look for preoperative
determinants of postoperative complications. This retrospective study found complications did
not correlate with any preoperative parameter measured.
 
Liu at UCLA, used the California inpatient discharge database. All gastric bypass operations from
1996 to 2000 were identified. Demographic, comorbidity, complication, and volume data were
obtained. Liu found that in California during those years complications were more likely in men
and in patients with comorbidities. Furthermore, when examining the effect of volume, patients at
very low (less than 50) and low (50-99) volume hospitals were much more likely to have
complications compared to patients at high-volume hospitals, even after controlling for
differences in case-mix. Liu concluded, “This study identifies three independent predictors of
complications: gender, comorbidity and hospital volume."
 
Iglezias and others present evidence that rapid weight loss may increase the risk of cholelithiasis.  
Prolonged hospital stay, fasting, and other conditions are known to increase the risk of
cholelithiasis.  Thus, there is some concern in the literature that rapid weight loss, possibly
interpreted to include mandated weight loss so that one could receive bariatric surgery, has
complications.
 
In the Swedish Obese Subjects (SOS) study Torgerson presented data demonstrating that surgical
subjects showed a definitive decrease in hypertension and diabetes while such decrease was not
evident in the non-surgical group.
 
 

pulmonary emboli. Sapala found that a combination of risk factors, specifically, venous stasis
disease and BMI > 60, and truncal obesity identified a high-risk cohort of patients who should be
strongly considered for pre-operative placement of inferior vena cava filters.
 
Livingston performed univariate analysis on ten potential risk factors for bariatric surgery
complications. Univariate analysis revealed that male gender and weight were predictive of
severe, life-threatening adverse outcomes. Multistep logistic regression yielded only male gender
as a risk factor.  This group analyzed more factors than other groups, and performed multistep
logistic regression – that demonstrated that only gender was an independent risk factor.
 
Perugini used an inception cohort to attempt to identify factors predictive of bariatric surgery
complications. Multivariate analysis by stepwise logistic regression identified surgeon
experience, sleep apnea, and hypertension as predictors of complications. Neither BMI nor
truncal obesity were found to be predictive of complications in this inception cohort study.   
 
Courcoulas explored the volume-outcome relationship for gastric bypass surgery. The
Pennsylvania state discharge database was utilized to identify 4685 cases of gastric bypass
surgery for obesity between 1999 and 2001. A significant risk-adjusted relationship between
surgeon volume and adverse outcome was revealed with the same trend observed for deaths.
 
Schwartz examined a database of primary bariatric surgeries to look for preoperative
determinants of postoperative complications. This retrospective study found complications did
not correlate with any preoperative parameter measured.
 
Liu at UCLA, used the California inpatient discharge database. All gastric bypass operations from
1996 to 2000 were identified. Demographic, comorbidity, complication, and volume data were
obtained. Liu found that in California during those years complications were more likely in men
and in patients with comorbidities. Furthermore, when examining the effect of volume, patients at
very low (less than 50) and low (50-99) volume hospitals were much more likely to have
complications compared to patients at high-volume hospitals, even after controlling for
differences in case-mix. Liu concluded, “This study identifies three independent predictors of
complications: gender, comorbidity and hospital volume."
 
Iglezias and others present evidence that rapid weight loss may increase the risk of cholelithiasis.  
Prolonged hospital stay, fasting, and other conditions are known to increase the risk of
cholelithiasis.  Thus, there is some concern in the literature that rapid weight loss, possibly
interpreted to include mandated weight loss so that one could receive bariatric surgery, has
complications.
 
In the Swedish Obese Subjects (SOS) study Torgerson presented data demonstrating that surgical
subjects showed a definitive decrease in hypertension and diabetes while such decrease was not
evident in the non-surgical group.
 
 
Blue Shield of California: Morbid Obesity Surgeries and Guidelines. Published Spring 1997 with last
review date of January 22, 2001.
 
Husemann H. Open-surgery management of morbid obesity: old experience-new technique.
Langenbecks Arch Surg, 2003;388(6):385-391.
 
Moose D, et al. Laparoscopic Roux-en-Y gastric bypass: minimally invasive bariatric surgery for the
superobese in a community hospital setting. J Laparoendosc Adv Surg Tech A, 2003 Aug;13(4):285-
289.
 
Argeaga JR, et al. Interval jejunoileal bypass reduces the morbidity and mortality of Roux-en-Y
gastric bypass in the super-obese. Am Surg, 2003;69(10):873-878.
 
Oliak D, et al. Short-term results of laparoscopic gastric bypass in patients with BMI> or = 60. Obes
Surg, 2002;12(5):643-647.
 
Kreitz K and Rovito PF. Laparoscopic Roux-en-Y gastric bypass in the “megaobese." Arch Surg,
2003;138(7):707-709.
 
Liu JH, et al. Characterizing the performance and outcomes of obesity surgery in California. Am Surg,
2003;69(10):823-828.
 
Pope GD, et al. National trends in utilization and in-hospital outcomes of bariatric surgery. J
Gatrointest Surg, 2002;6(6):855-861.
 
Dindo D, et al. Obesity in general elective surgery. Lancet, 2003 Jun;361(9374):2032-2035.
 
Blouw EL, et al. The frequency of respiratory failure in patients with morbid obesity undergoing
gastric bypass. AANA J, 2003;71(1):45-50.
 
Cooney RN, et al. Analysis of cost outliers after gastric bypass surgery: what can we learn? Obes
Surg, 2003;13(1):29-36.
 
Fernandez AZ, et al. Experience with over 3,000 open and laparoscopic bariatric procedures:
multivariate analysis of factors related to leak and resultant mortality. Surg Endosc, 2003 Dec.
 
Sapala JA, et al. Fatal pulmonary embolism after bariatric operations for morbid obesity: a 24-year
retrospective analysis. Obes Surg, 2003;13(6):819-825.
 
Perugini RA, et al. Predictors of complication and suboptimal weight loss after laparoscopic Roux-
en-Y: a series of 188 patients. Arch Surg, 2003 May;138(5):819-825.
 
Courcoulas A, et al. The relationship of surgeon and hospital volume to outcome after gastric bypass
surgery in Pennsylvania: a 3-year summary. Surgery, 2003;134(4):613-621.
 
Schwartz ML, et al. Laparoscopic Roux-en-Y gastric bypass: preoperative determinants of prolonged
operative times, conversion to open gastric bypasses, and postoperative complications. Obes Surg,
2003 Oct;13(5):734-738.
 
Podnos YD, et al. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch
Surg, 2003 Sep;138(9):957-961.
 
Iglezias C, et al. Impact of rapid weight reduction on risk of cholethiasis after bariatric surgery. Obes
Surg, 2003 Aug;13(4):625-628.
 
Torgerson JS. MMW Fortschr Med, 2002 Oct;144(40):24-26.
 
Torgerson JS and Sjostrom L. Int J Obes Relat Metab Disord, 2001 May;25Suppl1:S2-S4.
 -------


Rock

Thanks Rock,

I have seen this on the DMHC site and it will be included in the grievance to Kaiser ( do you think they'll read it LOL??) I also tried to find the recommendation on the NIH website that states they  support diet before bariatric surgery (as the Kaiser pamphlet says they do) but am only able to find that NIH is currently conducting a study on this very subject-----no results yet, although they hypothesize the diet and classes will make a difference.

Just to add to what Dr. Larra said. She’s always too kind to yours truly. Thanks you, Larra!

If sis Is seeking the DS with Kaiser, her game plan should be to get fully approved for WLS without even mentioning the DS at this stage. At which point the fun begins and upon moving through internal appeals she'll likely be approved and end up with your surgeon, absolutely world class!

Once fully approved for WLS, she would likely need to and pay for her own DS consult to get the ball rolling which should later be reimbursed upon DMHC  overturning Kaiser'sl denials of her internal appeals, but it's all doable and precedent aplenty exist.

Sure, Kaiser will read it... and file it appropriately.  Likely the same place I file the few ED (erectile dysfunction) ads I still get as spam. Although, the older I get I wonder how long it will be before I might want to start paying attention to those. Oh, bother.

.

Rock

Much appreciation to Rockne for posting the DMHC document!
    Brenda, I do feel that pre-op education is important. But 6 months of classes seems excessive and IMHO constitutes more of a barrier to care than anything else. And if there is also a waiting list just to start the classes, that is a further barrier and delay of medical care. As to the quality or usefullness of the classes, I can't say, having never participated in them, but maybe some other people can address this.
    I do know that the classes are oriented towards RNY and lap band. If your sister wants the DS, a lot of the information provided will not of value to her.
    As to timing of grievances, just make sure she is "approved" for bariatric surgery. Once she is approved they can't "unapprove" her just because she files a grievance.
    And again, if she is interested in the DS, there is help available for her (and anyone else interested) with grievances, IMR (independent medical review) requests, etc. from folks on the DS forum.

Larra