process puzzled

Hi everyone,
It seems I'm posting a lot of questions lately but my primary doctor has left me puzzled. When I told him I wanted to have wls he asked me if I would be willing to see a nut for 3 months and see what I could do on my own. So I said I would try but 2 weeks later I received a letter telling me I had been refered to the bariatric education class and to call and register. I was really excited because I felt like I had been bullied into waiting anyways (I'm a classic "people pleaser") But when I called to reg I was told there was no class date set yet and that I would be placed on the waiting list. So I'm confused where to go from here. Should I make an apt with my dr. to start getting my monthly weight check appts. and clarify with him that yes this is the direction I'm going. Or do they explain the procedure when you get in this class? I have Aetna insurance and am assigned to the Facey HMO here in northern LA county. I just want to get a jump on whatever I need to do to get approved asap.
Thanks for reading this rambling, confuded semi-vent !

Darn, I really wish I could be of help other than to say... Call your PCP and ask what program he has given you a referral for WLS, if they aren't done the classes then you need something else.

HUGS
JOY

 In the state of CA you don't have to do a supervised diet or lose 10% of your weight before WLS.

Many insurance companies/ medical groups/ doctors make patients do a medically supervised diet to stall. They are hoping that you will fail at the diet so that they can deny you, they can say you didn't follow the diet exactly so they can deny you, you will give up and go away, you change insurance before you complete the WLS process, or you will die before they pay for services.

Stop being a people pleaser. You need to be your own advocate and demand the services that you are entitled to.  Call up your insurance and file a grievance about having to do the supervised diet. 

You need to know that in the state of CA you do not have to do the 6 month diet. If you meet NIH criteria for WLS (BMI > or = 40 with no co mobities, or BMI > or =35 with co mobidities) then your insurance should cover your WLS (unless you have an exclusion in  your policy) You do not need to lose weight prior to WLS. Once you are identified as a candidate for WLS dieting or losing weight will not help you. In the state of CA we are very fortunate to have a department that oversees HMOs. The Department of Managed Health Care (DMHC) is very pro WLS. They have a peer review that shows that the 6 month diet, and weight loss prior to WLS is not medically necessary and actually might cause more harm than good. There are no medical studies or peer reviews that show that it is effective:.

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.
Here is the link:
http://www.dmhc.ca.gov/aboutTheDMHC/org/boards/cap/Bariatric REV.pdf

If they still will not refer you to a bariatric surgeon without the diet then call up the DMHC and file a grievance with them. They will overturn you insurance denial and make your insurance refer you to a bariatric surgeon.  Hopefully you won't have to go through all the hassle but once your insurance gets the grievance maybe they will magically open up a class so you dont have to wait and start.

Here are a few decisons where the DMHC has overturned insurance denial based on patient not doing the medically supervised diet. If you go on the DMHC's website you can find more examples and include them in your grievance to your insurance company.
DMHC IMR reference ID MN08-7582
http://wp.dmhc.ca.gov/imr/detail.asp?id=7582&optFormat=html& cboDetermination=Overturned+Decision+of+Health+Plan&cmdSearc h=Search&cboMC=Morbid+Obesity&cboTreatment2=0&cboDiagnosis2= 0&cboDT=0&cboType=0&txtDetails=
A 49-year-year-old female has requested laparoscopic duodenal switch (DS) bariatric surgery in lieu of vertical sleeve gastrectomy (VSG) without completion of the Options Program for treatment of morbid obesity. Findings: The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a BMI of 51.7 and co-morbidities that will likely be ameliorated or eliminated by bariatric surgery. With regard to the Options Program (I think this is Kaiser's bariatric program they make patients do), there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese. In addition, recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese. If a psychological evaluation has not occurred, one should be conducted to ensure the patient is an appropriate candidate for surgical weight loss. The patient has a need for long-term treatment with NSAIDs making the Roux-en-Y gastric bypass (RYGB) procedure a less tenable option. Laparoscopic gastric banding is not likely to be as effective as other surgical alternatives. The VSG procedure is a component of the biliopancreatic diversion with duodenal switch procedure (BPD/DS). VSG is an appropriate first step and may facilitate adequate weight loss for the enrollee. VSG is a less risky procedure than the full BPD/DS and moderate weight loss will be achieved without severe side effects such as dumping syndrome or malnutrition. If weight loss is not adequate (< 40% of excess body weight) and/or comorbidities do not improve, a staged conversion to BPD/DS is possible and would be indicated if treatment with NSAIDs continues.

http://wp.dmhc.ca.gov/imr/detail.asp?id=7949&optFormat=html&cboDetermination=Overturned+Decision+of+Health+Plan&cmdSearch=Search&cboMC=Morbid+Obesity&cboTreatment2=0&cboDiagnosis2=0&cboDT=0&cboType=0&txtDetails=

http://wp.dmhc.ca.gov/imr/detail.asp?id=7998&optFormat=html& cboDetermination=Overturned+Decision+of+Health+Plan&cmdSearc h=Search&cboMC=Morbid+Obesity&cboTreatment2=0&cboDiagnosis2= 0&cboDT=0&cboType=0&txtDetails=

Please see my post in my signature and please feel free to PM if you need any further help.

PS while you are in the beginning phases of getting WLS I would urge you to research all your options. Have you checked out the DS or VSG? Make sure you make an informed decision and best of lluck.

Call Facey and ask for member services and tell them what is going on.  IF you get no answer there march up the chain.  Be your own advocate for god sake this is your health.  This is not a cosmetic procedure.  I would make the appointment for monthly weigh checks. Just to show that you are proceeding as you need to.
Where in No LA county are you. Are you in Santa Clarita?
I know that there is a lot of controversey oer the required wt loss and classes. Well, to be perfectly honest the people who have some kind of class seem to be pretty successful.  I am tell ing you this as I work in this area in the surgeons office and I do see it.  I am sure that I will get some flaming for this but it is my opinion and observations
Liz

 No flaming here just an observation. Not all of us are able to live in areas where we are offered many medical groups or doctors to choose from. I was one of those people. I lived in an area that only had 3 medical groups and they all gave me and other people I know the run around about getting referred to a bariatric surgeon. They say that they want you to do the medically supervised diet to show that you are "serious" about losing weight and changing your old eating habits. How can they judge your level of commitment?( How do they know that the only reason for our obesity is overeating, not every MO person got MO from only overeating). Isn't that what the psych eval is for? The medical groups/ insurance/ and even some doctors are only out to make money and want to stall as long as they can. 

I am not against anyone doing the diet if they want to. But it shouldn't be a hurdle that we have to jump just to get a medical service we need and deserve. Do they make smokers give up smoking for x number of months, document that they aren't smoking, make them go to support group meetings before they will give them a referral to a specialist for their lung issues?
Why is obesity different ? Obesity is a disease. You can tell if someone is obese so I guess it's okay to discriminate against them. It would be wonderful if every medical professional viewed obesity as a disease instead of thinking of it as a character flaw.

I post all the time about not doing the diet in the state of CA. I really doubt anyone listens. But I just want to get the information out there, so if someone is in a position that I was in, will have a way to get a service they need. Even Medicare doesn't require a medically supervised diet. Most of us who have been MO have tried and failed multiple diets before we consider WLS. No one chooses WLS as their first option for weight loss.

This like everything else you read on the internet is just information, it is up to the individulal to decide for themselves what they will do with the information. This in alot of way reminds me of the way people on the mainboard and this board jump on DSers for even suggesting the DS. Why is it bad to offer different opinions and make someone's life easier if you already have been there and done that? This is from Medicare's website:

Medical therapy prior to surgery

One bariatric surgery group wrote that it favored bariatric surgery for those over age 65 and standardized facility criteria, but believed that a medical treatment weight loss trial for 6 to 12 months was not necessary. They commented that the decision of when to perform surgery was best left to the surgeon and the patient.

Generally, a common comment introduced pertained to the subjective nature of the medical treatment requirement prior to surgery. Some stated that there were no data to support such a requirement and others stated that the requirement only prolonged the time to needed surgery.

The standard of care for any surgical procedure is that medical management options are exhaustively considered and exercised by both patient and physician prior to surgery. This standard applies to the treatment of co-morbid conditions related to obesity. We will not impose a specific time period, but expect all surgeons to be part of a comprehensive program for the treatment of co-morbid conditions related to obesity and to have applied principles of good medical care prior to surgery.
https://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?from2=viewdecisionmemo.asp&id=160&

Sometimes I honestly do not even want to post on this message board because my posts (for the most part are ignored) I can't tell you how many times I've seen people come on here and whine about not being able to get referred to a bariatric surgeon or how they can't lose 10% of their weight so their surgeon won't do surgery. I post this to them and they keep on whining and complaining. I'm not telling anyone to cheat the system, because as you can see the system (i.e the Dept of Managed Health Care and Medicare) agree that you shouldn't be required to do the supervised diet if you are identified as a candidate for surgery.

This is from my original thread on this topic:
I still did the 6 month diet with my PCP during the time I was waiting for my consult and all my medical clearances. Just because you get the consult approved doesn't mean you're going to just stroll into the surgeon's office the next day and get a consult with him/her and get a surgery date. You have to attend their seminar (some only have them once or twice a month), you have to do medical clearances, blood work, EKG, upper G.I, psych eval, etc. If you have a HMO you know these things can not just get done right away they take weeks for appointments. That's why I'm saying if you can get your PCP to refer for the consult without doing the 6 month diet, it will go that much faster. If you do the 6 month diet, who's to say that your medical group/ insurance won't still deny you? At least this way you'll get a head start.

As you can see I still did the diet. I'm just trying to get the information out there that that one requirement shouldn't be used tostop or deter them from getting bariatric surgery.

If everyone appealed this requirement, insurance companies would not be able to use this to deny MO patients bariatric surgery. The decision on whether or not a patients should do the diet should be up to the patient; just like the choice of surgery a person gets  should be left up to them, not a doctor who is paid by a medical group, who is paid by the insurance. Just my .02

Well, I am glad that we are able to voice our opinions here.  I too live in an area with 2 medical groups and Kaiser.  I actually thought that but it is not the way that I see it or the surgeon that I work with. Crap, I know the waiting sucks I know the diet sucks. This is an elective procedure many people need that time to get their head around what they are doing.  I see it day in and day out. If people choose to fight that is fine.  This is my opinions and observations.  I myself did the 6 month thing.  But again I see the fight that many have before and have after.

Thanks you guys for the response. I will make make an apt with my pcp tomorrow. You both are absolutely right, I need to be my own advocate. Putting other things before what I want and need is a big part of what got me here in the first place. Thank you so much for that information about the HMOs and requesting an alternate surgery. In my research I have done I feel the DS is best for me but was concerned because it is not one of my choices my insurance gives me. Now I know I dont always have to do exactly what they tell me. This goes a long way in helping me feel comfortable with my choice of having wls.
Thanks again!
Oh and yes, I do live in Santa Clarita.

Aetna does cover the DS. They may not widely advertise it or state that they only cover for patients with a BMI > 50 but this is not true. In the state of CA if your insurance will cover RNY or lapband then they have to cover DS. The Dept of Managed Health Care insures this. I just won an independent medical review with the DMHC for the DS after my insurance denied me twice. If the DS is what you want please do not give up in getting it. Feel free to PM me and I will gladly help you thorugh out the process. No matter which surgery you choose, please research all your options and don't ever settle on what someone is willing to give you, but get what you can live with. Best of luck