Approved

(deactivated member)
on 12/31/08 10:09 am - sunny, CA

I'M APPROVED FOR THE DS

I can't believe that after fighting for WLS for over 5 years I've been approved for the DS. I called the DMHC again this morning and was told that they had a decision but could not tell me over the phone... But she offered to fax it for me. She said I would be happy with the news. Me being the pessimest I am had to see the letter with my own two eyes. Here's what it says:
Your request for coverage of duodenal switch with biliopancreatic diversion was referred to the Department's Independent Medical Review organization, where Independent medical providers resolve disputes about health care services.
In your case, the independent providers determined that the service you requested is medically necessary. This decision overturns the original denial by Health Net. The services must be authorized within five working days.

I just want to remind everyone out there that if you are having insurance problems or if you have doctors telling you that you shouldn't have WLS, you're too young, they won't cover it blah blah blah, know that you can fight and win. I did. Who would've thought that I would ever be able to do this. I certainly didn't most days. I'm so happy that I saw this thing through and finally believed that I was worth it.

In the state of CA you do not have to do the 6 month supervised diet or any bariatric program. I started my weight loss journey again in Feb 08 (I had to take a break from pursuing surgery when I got pregnant with my daughter in lat 2006). I asked my PCP at my first visit with her to refer me for a consult with a bariatric surgeon, she said I had to do a 6 month diet, I showed her the peer review from the DMHC, she gave me the referral that day. My medical group denied the referral, I appealed to my insurance and my insurance overturned my medical group's denial. I was approved for RNY in 5 months (the only reason it took so long is because I have a HMO and all the pre-op tests took forever to get scheduled).

After I got my RNY approval, I went back to my PCP and asked for a referral for the DS (duodenal switch) this was in Aug 08. She had never heard of it. She was concerned about malabsorption, I brought peer reviews and medical studies that showed the effectiveness of the DS long term. She said the choice of surgery is up to me since I have to live with it (finally a doctor who didn't think they knew what was best for me). She referred me that day. It was denied by my insurance, I appealed. It was denied again, I appealed again, after the second denial I had the right to ask for an IMR with the DMHC. I faxed my IMR to the DMHC on Nov 17 and today found out that the DMHC has overturned HN's denial and I am approved for the DS.

Research all your surgicial options (DS,VSG,RNY and lapband). Decide which one you can live with and never give up on getting insurance approval. We are very fortunate to live in the state of CA and have an agency like the DMHC who is pro WLS and will help patients get the WLS of their choice. You just need to educate yourself and be your own advocate. Never give up!!!!!!

soon2bdoll
on 12/31/08 10:38 am

RNY on 02/04/09

CCongrats to you....it took me 3 years and filing appeals and they finally approved me....my surgery is Feb.4th.....it takes persevearence (sp) i thought it owuld never happen but it did.....you can neever give up......Do the Hppy Dance!!!!!!

(deactivated member)
on 12/31/08 10:45 am - sunny, CA

Thank you soon2bdoll. I hope newbies and pre-ops will listen to our stories and not give up. We are very fortunate to live in CA and have so many options available to us. Happy New Year and good luck with your upcoming surgery.

jj_in_CA
on 12/31/08 11:37 am - Gualala, CA

RNY on 07/09/08

Congratulations you must be elated!

---jan---

(deactivated member)
on 12/31/08 11:51 am - sunny, CA

Thank you JJ. I am beyond happy. I can't believe it's finally happening for me. Thank goodness we live in Ca and have the DMHC. Happy New Year to you.