I want a DS- insurance appeal/ IMR questions

Hello everyone-

I have been denied on appeal for lap band revision to RNY because there is no mechanical failure of the band, and they say I have been non-complaint. I think I can get around the non-compliant, but I can't MAKE something break with the band!

I am now able to appeal to the IMR (I am in CA) but I DON"T REALLY WANT an RNY! I want a DS.

Should I appeal anyway and try to change to a DS if I get approved, or should I just start over with a DS in the approval request? 

One final note: my husband got a new job and we will be getting Kaiser as of 8/1. Should I just wait and go through them?

 If you have insurance experience, please respond! I want to do the right thing!

Thanks!

Kaiser is a ******g pain in the ass for the DS, especially revisions.  But I can't say they are worse than the average insurance, so you may be in the same boat.

You are not going to get approval and surgery scheduled before 8/1 anyway.  I'd wait, and start the process with Kaiser, and go for the DS from the git-go.  Which Kaiser are you going to be with - NorCal or SoCal?

 Our Kaiser will be So. Cal. BUT I forgot to mention that I also have insurance with my employer through CIGNA HMO and that is who I am using right now. I am not losing that coverage, I am just gaining Kaiser so that I will have two insurance coverages. Does that make a difference?
 

You are already out of my limited area of expertise - I don't know how the plans would manage coordination of benefits.

CIGNA has been a PITA too.  One question for you is whether your CIGNA plan (and/or the Kaiser plan for that matter) falls under the control of the CA DMHC, because not all plans do.  You want to make sure that you are using whichever plan is under their control, because in the end, if you have to appeal, you want to be able to appeal to them.  Check with HR.  Just because YOU live in CA doesn't guarantee this, as I know all too well - my last two plans have been BCBS plans from NJ and now MD, where my employers' main offices are located - I am on a Blue Card PPO plan, so I can see my doctors in CA in-network, but the DMHC doesn't have jurisdiction over either of them.

 YEE****hanks for the info- I'll call HR. Who would have thought my plan might NOT be administered in CA. Aarrggh!

Hi Lori,
I'm at Kaiser of So Cal and it is definitely a pain in the ass in regards to weight loss surgery in general.  They have all sorts of hoops they want you to jump through--but they'll give you the RNY if you want it.  They'll want you to join their Options group and take 12 weeks of classes--of which you can't miss ANY.  They'll require you lose 25% of your weight before surgery.  There are no exceptions once you are in that program.  So, I've bypassed the program.  I opted to see a surgeon first--which automatically kicks me out of the Options Program.  As far as the DS is concerned, I'm new at this, but they're definitely not happy that I want the DS.  I've spoken with the people *****fer you to the surgeon--they are in the health ed department, and they were really against the DS--and VERY rude about it.  They were trying to make me feel stupid as if I didn't do my research.  These are registered nurses I'm speaking of and I swear they knew NOTHING about the DS.  All that they told me seemed to be related to the old jej. bypass.  In any case I just stood my ground and now I'm going to see the surgeon tomorrow.  The surgeon is the next hurdle because it's totally up to him as to whether or not he wants to give me the DS.  My back up plan is to appeal to the DMHC if he says no. Next, I'll go see a out of network surgeon to give me a letter stating that it's the best surgery for me and why.  Then I'll take that to the DMHC.  It's going to take lots of time and patience--but I imagine it might be just as difficult with any insurance company. Were I in your shoes I'd contact Cigna and see what their process is like.  

Now one word of caution--your fight may or may not be harder because you're doing a revision--and not for a failed band but because it didn't work for you, right?  So I don't know how Kaiser would handle that. 

If you need support (can't offer much advice since that's what I use OH for!) private message me!

Sheri 

Good luck to you and thanks for the response. I think I am going to stay with Cigna until I exhaust them and then go to Kaiswer only if I have to. I've already been denied on appeal twice with Cigna, darnit!

Not sure if you have read this article written by Diana Cox on the DSFacts website or not

http://www.dsfacts.com/Insurance-Says-DS-Investigational.htm l


Good info for you.


-Jamie

I would just add that if you do go the IMR route (and I suspect you will have to, regardless of which insurer is involved), DO request the DS and not RNY. The last thing you want is to win for the RNY and then get told, ok, so we'll pay for your RNY but not DS.
     You would then need to start the process all over again, with, IMHO, less chance for success because you would look like you don't know what you're doing.

Larra

Hmmm- someone on this board suggested that since it's easier to get approved for the RNY, to go for that and then, when I change to a DS, I will already be approved for WLS so I won't be fighting for approval, just the type of surgery. Thanks for your post- I have alot to think about! I don't know what to do!