Want a DS? Insurance says no? The CA DMHC ROCKS!!

Many insurance companies continue to callowly claim the DS is "experimental" or "not medically necessary."  They are lying, of course.  But in California, we are lucky to have, for most people, recourse to the California Department of Managed Health Care (HMO plans) and its parent organization the CA Dept. of Insurance (for PPOs).  These two complimentary organizations both use CHDR/Maximus as their external medical review organization, which has recognized the superiority of the DS.

Since mid-2004, the DMHC has overturned EVERY SINGLE REQUEST FOR THE DS that has been brought before it.

The reason I am bringing this to your attention today, is that in fact, there were two cases where this did not happen, but over the last few days, there has been justice served in both of these situations, and the above statement is now true.

In the first case, Kaiser insisted on providing a VSG to a patient who wanted a DS.  To our astonishment, the DMHC agreed, stating that if it didn't work for her, she could come back and get the switch added.  It didn't work (big surprise: the patient had a BMI over 50).  But Kaiser tried to prevent her from getting the switch added.  We (Larra and I) helped her fight back, and she has now WON her appeal at the DMHC.

In a second case, the DMHC decision, which is stated as being FINAL, upheld Kaiser's denial of the DS with some factually incorrect statements in the decision, failure to address certain aspects of the patient's medical condition, and a statement that the reviewing physician wasn't a bariatric professional at all.  We attacked the validity of the IMR, and the DMHC agreed to reconsider it -- AND OVERTURNED THE DENIAL!

If you want the DS, and your insurance plan is covered by the California DMHC and/or Dept. of Insurance, your chance of winning on appeal is virtually 100%.

Is Pacificare Ca covered by Californiahc and/or Dept. of Insurance

I don't know what your plan is -- you have to ask your HR Dept.  If your plan is self-funded, it would not be.  If your plan was "delivered" outside of California, it may not be.  You need to find out what your route of appeal is by asking HR what happens after you exhaust your internal appeals with Pacificare.

Diana is RIGHT as usual. That said, they’re listed with DMHC if this applicable with your plan and the other requirements Diana outlined.

------

Department of Managed Health Care
List of All Licensed Plans
Alphabetical Report

http://www.hmohelp.ca.gov/healthplans/gen/gen_licensed.aspx

This report provides the following plan information:

Plan ID number
Health Plan primary contact for DMHC
Health Plan street and mailing address
Type of plan
Date licensed
DMHC assigned staff

------

933 0126 - PacifiCare of California



dba: Secure Horizons, Health Plan of America (HPA)


Reports of Licensed Plans and Pending Knox-Keene Applications
The section below contains contact information specific to a plan maintaining its license in California. This list should not be used to contact the plan for questions regarding a plan's services or benefits.

Licensing contact information by Plan as of June 15, 2009. as of 06/15/2009

Awww there's Rockne my "hero"....

Thanks for posting this here, Diana. It was your post here on the CA board, a few months ago, that set me on the right path towards WLS. I had all but given up on surgery with Kaiser and seldom posted here but I signed in just to check on a few of my old friends. Luckily it was the day you posted. Now I know I will have a preferable surgery within the next month or so paid for by Kaiser.

Hello, California,

I am the first case that Diana mentioned--the VSG patient who wanted the DS.  All I can say to all of you is this:  If you are interested in the DS, research;  If you want the DS, don't give up hope and just go for it!  You've got the DMHC on your side!  As Californians we are so very fortunate.

Finally, justice has been served, and I am so grateful to Diana and Larra who give of themselves so generously!  I would not be where I am today without their help!

Thank you, Diana and Larra, again and again!

If any of you are interested in my story you can look at the post I made on the DS board right here.  My hope is that my story will give hope to those of you who are in the same boat I was in.  I hope my story will help those of you who may be struggling with your insurance company to get the surgery you want, not the surgery someone picks out for you!  

Terry