California Department of Insurance

Hi everyone..I live in Washington State, but my insurance is based in California.  I have Anthem BCBS of CA PPO and have been denied 3 times (initial denial, peer to peer review denial and appeal denial) for the VSG surgery due to investigational and submitted my info to the DMHC.. Come to find out I should have contacted the California Dept. of Insurance instead.. So now my paperwork goes to them to have one last fight for this. My question is... Has anyone had experience with the California Dept. of Insurance? I have heard lots about the DMHC, but nothing about California Dept. of Insurance... I can't self pay, so this is my only hope until the insurance company will cover VSG (whever that will be!!) I have posted this in the insurance forum and the vsg forum. I thought maybe I'd try you guys in California too! Any help is welcomed!! Thanks!

I am fighting right now with Anthem BCBS of California for a different health problem(has nothing to do with my wls), they denied by first submission and my appeal.  I went to the Cal. Dept. of Insurance and was told by them that they do not have any control over Anthem BCBS because the coverage they provide is set by your employer.  They told me to go to my HR Dept. at work and talk with the Insurance Advisor, that they would be the only ones that could override Anthems decision.  I am planning on calling them in the morning.  Good luck.

First of all, Tazfan is confused -- she apparently has a self-funded plan.  The CA Dept. of Insurance (which is the agency under which the DMHC exists) has no control over self-funded plans.  Recourse after exhausting internal appeals with the insurance company -- which is only ADMINISTERING the self-funded plan, using its doctors and policies, but the bills are actually paid by the employer -- is through an internal medical review committee of the employer, OR the employer may farm it out themselves to an independent medical review agency.

Now, to what it appears is your situation.  You apparently have a fully funded PPO, which is under the authority of the CA Dept. of Insurance.  Since it is not an HMO, you don't use the process of their subagency, the DMHC, but have to go through the DoI process, which is pretty similar.  In fact, both the DoI and the DMHC send their independent medical reviews to the same place, an IMR agency called CHDR/Maximus.  So resubmitting the appeal you incorrectly submitted to the DMHC should be quite straightforward.

Now for the bad news.  You are most likely going to lose.  CHDR/Maximus generally agrees that the VSG is experimental.  Moreover -- and I hope you already know this and are just holding out because you are undulyworried about or have been misinformed about the malabsorption issues with the DS -- the VSG is much less likely to be sufficient as a WLS for you because you are SMO.  In fact, I think the multi-year data are stacking up pretty solidly against using it for people with a BMI >45.  Not that you CAN'T succeed, but your odds of being successful long term are signficantly poor -- so poor that it is my understanding that even LapSF isn't recommending it for SMO patients anymore.

And a further warning: if you are thinking of the VSG as a 1/2 way measure, and if it doesn't work out for you in a couple of years, you can "just" add the switch, you may be in for a very rude awakening:

* You might not have insurance in 2 years

* You might not have insurance that will cover WLS in 2 years

* You might not have insurance that will cover a revision in 2 years

* You might not qualify for WLS (i.e., ending up at a BMI of 39.5 with no significant comorbidities) in 2 years

* You might be facing another "5 uninterrupted years of morbid obesity" qualification in 2 years and will not qualify for another procedure

* In 2 years, your sleeve may be stretched out so much that resleeving you will be required to get any significant weight loss (remember that the weight loss in a DS is substantially from the restriction, but is maintained by the malabsorption -- non-MO diabetics who get just the switch don't lose much weight) -- and resleeving is significantly more dangerous than making a virgin sleeve -- the surgeon is operating on scar tissue and adhesions, and if the entire old staple line isn't completely removed, the surgeon will be stapling over old staples and this creates an area of weakness and therefore increased risk for a leak.  Because of this, at least one of the most experienced lap surgeons, Dr. Rabkin, insists on doing the resleeve open. [Edited to clarify the reason for the increased danger of resleeving and the necessity of doing it open.]

I STRONGLY urge you to reconsider your decision to have the VSG, because of these factors.  You WILL almost certainly win your IMR for a DS, but not for a VSG.

Thank you for your responses. I will take that into consideration.
I actually used to weigh about 500 lbs. (I stopped going to the Dr. after 470).. I have lost about 130 lbs on my own and am basically stuck at my weight now and truely feel that the VSG is the best one for me. I don't want to get down to what the Dr's say is a "normal" weight... But want to get down to something that's "normal" for me. Also, in my research, I had found that for people that have a really high bmi, the VSG was good for them and easier to operate on and had shown to lose 100 plus lbs... I could be wrong.. But anyway, thanks so much for your info and I will let you know what the Cali. Dept. of Ins. says!

OK, I don't want to rain on your parade any more but ... if you started out at 500, and let's say your "ideal" weight (by BMI) is 150 (assuming you are 5'5"), then you had 350 lbs of excess weight from your top weight.  50% EWL (which is what is considered WLS "success" by bariatric surgeons) would be 175 lbs lost, which would put you at 325 lbs, or still Super Morbidly Obese.  I'm pretty sure you need to take your starting weight into account when you consider where your body's set point is, no matter how you lost your initial weight.  The same applies for anyone who loses weight before their WILS.

I think I know what you mean about not wanting to get get to "normal" weight, but I would think you would want to get out of the morbidly obese range.  If you started out at 500 lbs., I think it is even MORE unlikely that the VSG would be unlikely to help you that much.  I really hope you will reconsider -- the DS isn't likely to get you down to "normal" either, but it is a more powerful tool and at least should get you to 200-250.

Like Diana, I have doubts about the success of your appeal with the CA dept of insurance, because your insurer can argue that VSG is still investigational. And most likely they are right - it is only in the past few years that people began having the VSG as a stand alone (in other words, not as part of the DS), in any numbers. The VSG is not endorsed, at least not yet, by the ASMBS, or the NIH, or Medicare, or any other major organization in the bariatric surgery world.
     I hope you will keep at open mind about the DS. It is endorsed by all of the above, so your insurer can't claim it's investigational (well, they can try, but they will lose). We have seen many denials for the DS be overturned on external appeal - not so for VSG. There are excellent studies published documenting the longterm results of the DS not just for weight loss, but also for nutritional health and resolution of comorbidities. Because there is much less of a problem with weight regain with the DS than with RNY, the results for the DS in percentage excess weight loss and also for resolution of comorbidities are the best of any wls out there. If I knew the longterm results for VSG I would gladly present them, but they are not known. Some 3-5 year results are just becomming available, and they don't look so good, esp for people with higher bmi's. Short term results can look good for almost any operation with significant restriction, but what happens after 2-3 years? That's the big question.
    And as Diana said, it's not a question of getting skinny or to a "normal" weight - with a high starting bmi, you are likely to remain MO or at least obese with any purely restrictive operation.
    If you would like some great articles about the DS, just send me a pm. If I had any articles about longterm results with VSG I would be happy to provide them, but they do not exist.

Larra

Thanks everyone!
I don't want any surgery done to my intestines therefore, the VSG is the only surgery option besides the Lap Band which I do not want. I do not want the dumping, malabsorption problems. I do not want to deal with the vitamin and mineral deficiencies (I know there is some with all WLS) but with the intestinal surgery, I believe, there's way more risk of that. I do not want to have to take as many vitamins and supplements that come with those sugeries.
Anyway, I really thank you guys for your help. If they deny me I guess I will have to just keep trying on my own and wait until it's not considered investigational. (See, I heard nothing but good things about the DMHC overturning VSG's AND DS, but nothing about the Calif. Dept. of Ins.  so that's why I was wondering.)

You are misinformed if you think there is dumping with the DS -- that happens with the RNY.

I am THRILLED to have exchanged tossing back a small handful of vitamins and minerals twice a day instead of a small handful of medications, plus getting to eat 3000 calories/day of primarily high protein, high fat foods, and getting to have a dessert as well.  I am almost six years out and I have NO deficiencies.  My bone densitiy at 56 is higher than the average woman in her 20s.

You heard incorrectly about the DMHC approving VSGs.  To my knowledge, they have approved the VSG once, where SoCal Kaiser insisted on providing just a VSG to someone who wanted the DS.  That unhappy person is now in the process of getting authorization to get the switch, as the VSG failed her, as expected.  As I stated above, the same reviewers do the IMRs for both the Dept. of Insurance and DMHC.  I expect that their position is NOT going to have changed, especially after this and especially for people with higher BMIs, unless there is some medical reason that malabsorption would be inappropriate for a particular person.