Heather S.
In May of 2005 I was referred to the Kaiser Bariatric Program by my primary care physician. I was 216 pounds and 5’0 tall with a BMI of 43 with gurd, chronic back pain, depression and degenerative joint issues in my hips and knees. I had to fill out an 18-page questionnaire and mail it back in. June 10th I was mailed a denial letter from Kaiser’s program manager, Mary Lou Greenwood, denying my request to enter their program. The reasons provided were that I did not meet their guidelines for entry into the Bariatric Program, which are:
BMI of more than 50 with no co-morbidities
Or
BMI of 40 – 50 with two of the following life threatening co-morbidities:
1. Uncontrolled sleep apnea documented with sleep study and uncontrolled with CPAP therapy
2. Degenerative joint disease of hip, knee, or ankle with abnormal x-rays and a recommendation from an orthopedist, rhumatologist or physiatrist for joint replacement
3. Congestive heart failure and cardiomyopathy
4. Obesity hypoventilation syndrome with Pa02<55 and/or PaC02<42 with evidence of right sided congestive heart failure
5. Diabetes mellitus refractory to conventional treatments
6. Hypertension refractory to conventional treatments
7. Refractory extremity edema with ulceration
8. End-stage renal disease with difficulty dialyzing
9. Severe low back pain if patient is significantly disabled, has x-ray changes in the spine, a specialist recommendation for weight loss and/or back surgery
10. Gastroesophageal reflux not controlled with medical management
11. In unusual cases the relevant specialist may recommend surgery after evaluation of Amenorrhea related to obesity, Incontinence related to obesity and Pseudotumor cerebri
So in other words you have to be so large you can hardly even move and couldn’t possibly move without pain or if you don’t have a BMI of over 50 you’re on your death bed. Their guidelines do not meet the National Health Institutes standards for determining medical necessity and therefore are baseless. Kaiser has just come up with their own rules for determining who is and isn’t eligible for surgery without following any guidelines but their own.
So I appealed their decision and went to Obesity Law and Advocacy Center, who filed the appeal letter with Kaiser and handled the hearings for me. I gave testimony at the hearings by phone and we submitted documentation for Kaiser’s review.
In July of 2005 Kaiser denied my internal appeal and then Obesity Law and Advocacy Center filed an external review appeal and we resent all the information for the external reviewing doctor to look at and determine if the surgery was medically necessary for me.
In august of 2005 the independent outside reviewing agency physician determined that before I would get eligible for surgery until I had completed a multidisciplinary weight loss program through Kaiser.
So in August 2005 I enrolled in the 12 week Freedom from Diets weight management class through Kaiser. I completed the class in Late November of 2005 and then called the Bariatric Program and asked that they now admit me into the program and they refused stating that just because I completed the 12-week program doesn’t mean that I now am eligible. They disagreed with the meaning of the reviewing agencies letter stating that I was to complete a multidisciplinary program. They didn’t feel that just finishing the class allowed me entrance into the program.
So I contacted Obesity Law and Advocacy center again and Kelly Brown was wonderful. She could not believe the crap Kaiser was pulling and she said she would handle this appeal with no charge. We again filed an appeal with Kaiser and in January 2007 I was denied. We immediately filed for an outside independent review and this time I mailed everything I could possibly find regarding all the weight loss clinics and weight loss programs I had tried in the past. I sent all of my LA Weight loss dairy entries and all my Jenny Craig dairy entries.
In April of 2007 I got the decision back from the Independent Reviewing Organization and I was APPROVED and it was found that bariatric surgery IS medically necessary!!!!!
I couldn’t be happier. Now I just had to jump through Kaiser’s hoops. And there are Many Many Many hoops.
First Kaiser stated that all their orientation classes were full until August and then the Oregon Insurance Division was called and then in May I was allowed to attend Kaiser’s orientation class (2hr class) that explains the process you are expected to follow and the different expectations they will have for you prior to being allowed to have the surgery. Then next you are required to attend another informational meeting with the physical therapist, and the surgeon where they explain what you can expect to get out of the surgery and what the surgeons are looking for when it is time for them to approve you for surgery. Because I was already approved for surgery I was really not too worries when it was stated that you were required to loss 10% of your weight before they would consider you for a surgical candidate. At first they also claimed that this class was full and I had to have the insurance commission call again and I was bumped into the May class. And the classes were NOT full when I attended. Each class had about ten people in them.
In June I went to my first Bariatric support group meeting and I really learned a lot from others there about what the surgeons are looking for and what was expected of others prior to their surgery and I was also able to meet some people that were still in the waiting process like me.
Next after the last orientation class if you had already completed the 12 week Freedom From Diets class you could sign up for a meeting with the dietician and the licensed social worker. When I called for my appointment I was told that the next available appointment was not until September! SEPTEMBER! It was May for gawd sakes. I immediately called Kelly with the Obesity Law and Advocacy center and voiced my frustrations. She then called the head of Kaiser and let Jill Vaughn, the head of Kaiser Human Relations Department, know how extremely frustrating and unhappy we were about this whole process. Kelly also contacted the Oregon Insurance Commission, they also called Kaiser, and I’m sure Kaiser was told to stop stalling and allow me to have the surgery and get me through the process as soon as possible.
Next thing I know I received a call from Mary Lou Greenwood, the Bariatric Surgery Head Honcho, stating that there had been a cancellation and they could get my in to speak with the dietician and the social worker on July 26.
July 26, 2007 I met with the social worker and it went really great and she indicated the only thing she would even recommend and it was purely optional for me, was to have a visit with one of the bariatric physical therapists and see if there was anything they could help me with for my joint pain. I brought 3 months worth of food diaries when I met with the dietician and she said I was doing exactly what I needed to be doing and I didn’t need to work on anything just to keep doing what I was doing. At the end of the session with them both the dietician said as soon as I was ready to proceed to the next step of meeting with a surgeon to just call Mary Lou and make the appointment.
That same day I called and asked to schedule an appointment with a surgeon and Mary Lou Greenwood stated that prior to meeting with a surgeon I was required to meet with the Social Worker and the dietician again. I stated that the dietician indicated otherwise and she said that was their procedure. I then called the Oregon State Insurance Commission again and they contacted Jill Vaughn with Kaiser Human Relations and later that day I received a call from Mary Lou Greenwood of the Bariatric Department who informed me that she had put in an order for blood work and an order for an ultrasound of my gallbladder and that the scheduling department would be calling to schedule an appt for me to meet with a surgeon. YEAH!!!!
The next day I got a call from the scheduler and my appointment with the surgeon is for August 31, 2007 and I am meeting with Dr. Moiol.
I have heard that with Kaiser you will be denied access to surgery if you have not lost at least 10% of your weight prior to surgery. I don’t think that will pertain to me but I have been losing about 2 lbs per month for a bit now. I am down to 209 from 216 and the dietician stated that is exactly what the surgeon will be looking for. So I think as long as I don’t gain any I will be ok. I’ll just have to be sure to take a laxative the day of my appointment so I’m sure I will be a little less then 209 for sure. J
I have spoken with people that have had surgery through Kaiser and the surgery dates from the first meeting with the surgeon really varies widely. I have seen them anywhere from three (3) days after the first meeting to four (4) weeks after the meeting.
But at least I have a date to talk to the surgeon and I am hoping to have the surgery some time on September after the kids have gone back to school. I am getting so so excited now. Not really nervous yet but I am getting the planning done for what I will need to complete at home and work prior to surgery. And because I don’t know if it will be 3 days or three weeks after August 31, 2007 it is a little hard for me to plan for everything.
Well it's now September 2, 2007 and I met with Dr. Moiel on Friday and I have a date!!!! October 10, 2007. I could have had the date of September 6, 2007 but I opted to wait a bit longer because my husband's hunting season is the first three weeks of September. So this date is perfect. Plenty of time to get used to the idea and read up on everything, get all those last minute items I will need and time to get the final blood tests and testing completed without rushing around.
I am so happy. I have been waiting for this day for so long. I am more relieved then excited really - I can't wait to get going with my second chance.
