This is such a struggle--an Update

For those of you who don't know my story, I'm trying to get the DS through Kaiser of So Cal.  Thus far I've been referred to the Options Program (Kaiser's program for bariatric surgery) and approved to go through the program for any of the following surgeries: The Lap-band, the Sleeve, or the RNY.  I sent a grievance through asking to wave the Options Classes (since they don't cover the DS) , to wave the 10% weight loss requirement, and to send me to an outside surgeon for the DS.  My file was reviewed Friday.  I found out today that all grievances were rejected.  I am allowed to go see a surgeon within Kaiser--one who performs the DS but isn't a bariatric surgeon (does intestinal surgeries)  but that I'm basically kicked out of the bariatrics program.  They said that the surgeon would reject my request and send me back to them and that I'd then be put on a wait list for a few months before getting back into the program. 

I agreed to see the surgeon--Bookfairie (Laura) is helping me with the appointment.  I was upset that I am kicked out of the Options Program because if push comes to shove, I MAY have to take the classes so I'd rather just do them while I"m appealing this whole thing.  I'm also upset that they're so certain that the surgeon will turn me down. 

My plan now is to wait for the call to make the appointment for the surgeon, and in the mean time I'm making an appointment with Keshishian to see if he'll write a letter saying that he thinks this type of surgery is appropriate.  If possible I'll appeal to the DMHC to have Kaiser pay for Keshisian to do the surgery.  But at least when I walk into the Kaiser surgeon's appointment, I'll have a letter in hand that says someone else thinks it's appropriate. 

BTW, I cited the DMHC website regarding the class requirement and they responded saying that was insufficient evidence.  This sucks.  No fun.  I'm trying to keep my head up and stay strong.

Sheri

Man, what turds.  Keep your chin up...you'll get there.

ahhh insurance BS, always the same....keep on them, appeal etc.  you will get there...

I am trying to be proactive. So, I called Dr. Keshishian and made an appointment for early next month. Hopefully, he'll review my case and write me a letter stating that the DS is the only appropriate surgery for me. Next, I got a call back from the Kaiser surgeon and made an appointment to see him middle of next month. I'm hoping that when I arrive armed with Keshishian's letter he'll agree to do the DS on me. But with Kaiser one never knows. Worst comes to worse I'll have to send my grievance to the DMHC along with Keshishian's letter and hope they force Kaiser to pay him to do the surgery. This is a long process and it S-U-C-K-S.

S

I think that Kaiser only contracts with Dr. Rabkin in San Francisco. Kaiser sends people from at least as far as Colorado to have surgery there. I know Northern CA Kaiser has different policies, but I got my DS through them after appeals. I can send you examples of my appeal letters if you send me a personal email.

Actually here in So Cal, Kaiser used to send patients out to someone local.  But now they have someone in-house that they use.  Bookfaerie used him and said he was an amazing surgeon.  However, he's not very Pro-DS so I don't think I'll have an easy time convincing him to do the surgery.  She said it was a brutal consult.  Just for support--and some extra armory, I'm taking her with me to my consult next month.  The Woodland Hills Kaiser Health Ed department was appalled that I even wanted to consider this surgery.  They really don't seem to know much--I spoke with two nurses who thought the surgery was ancient and not practiced anymore.  I'm sure they were referring to the old junoileal bypass.  But there was no talking to them about it.  I'd happily drive or fly up to see Rabkin though.  Everyone has such nice things to say about him. 

Did they wave your Options classes and weight loss requirement? I'll send you a PM and you can send me examples of your appeal letters.  I sent a really good one and surprisingly it was not successful.
S 

I don't think N. CA has the options class,but maybe something similar. In any case, I did not have the class or the weightloss requirement. Thank goodness I couldn't lose the weight to get the RNY that I was approved for. Thank you Diana Cox for steering me in the right direction. You won't regret working for the DS. I will forward some things to you ASAP. (am having a bad, busy week)

One of my friends works for Kaiser (So. Cal) and I'm going to ask her if she can give me some "insider" tips on how to get Kaiser approval for the ds with less problems. If anybody will know Jenn will. I'll email her right now and hopefully she'll get back to me soon whether she has any advice or not. 

Thanks Kristina. I appreciate you asking.  I'm afraid though that once the appeal goes before the pannel of MDs there may be nothing anyone can do.  But any info your friend has to offer would be great!

Sheri

Re the Options program and weight loss issues: NOW you file a grievance with the DMHC.  They will almost certainly order Kaiser to waive the requirement - you must be joking if you actually thought KAISER would waive their own requirement!!

However, it is interesting that they KICKED YOU OUT OF THE BARIATRICS PROGRAM.  That could be an interesting twist on this - retaliation for exercising your rights.  Was any of that in writing?  I would ask for it in writing IMMEDIATELY (before you file the grievance even, so they don't know what you are doing).  I think the DMHC would be interested in this anti-patient policy.

I would argue that their statement that they were sending you to a non-bariatric surgeon (I am confused - is this Belzberg or not? and if not Belzberg, who arguably IS a DS surgeon within Kaiser, why not?) who would reject your request (are THEY dictating his response?) is a DENIAL of the DS, and go ahead and get a consult with Keshishian - that way, you can argue that you are getting a second opinion after being denied, and Kaiser has to pay for it (afterwards, when you win this whole thing - in the meantime, pay for it yourself).