ModestoK
Now serving: denial for outside authorization
Jul 26, 2010
I spoke with my Kaiser surgeon on the phone last week. Although he said Kaiser will not approve outside authorization for me getting the DS because of my 'low' BMI, he was very respectful and helpful in addressing my concerns. He also told me that I could fight, but I would be denied.
I took the weekend to further think about my options and to do a bit of additional research. He said that DMHC will not find the DS medically necessary in Kaiser patients with a BMI below 52 . He said he I can do the appeal process and that DS doctors actually have pamplets on how to do so, but I will be denied all through Kaiser and at DMHC because the DS is not medically necessary - I can have the VSG (even though I need the malabsorption aspect.)
He may have consulted on IMR's in the past, but what may have been true earlier in this century regarding the requirement that a BMI be over 52 for DS approval does not seem to be true any longer. Since the IMR outcomes listed on the DMHC do not specify BMI's for all cases, it makes it difficult to compare with my situation.
What I did find is that most of the cases upholding the insurance company's decision against the DS deal with patients that need revision or wanted other surgeries. From 2008 - present, using the search term Duodenal Switch under the morbid obesity diagnosis category, I found 1 case in 2008 and 2 in 2009. I think I can differentiate my sitiuation from those 3 cases -
MN09-10414 was a patient with a BMI under 50 but they ruled that the submitted evidence did not demonstrate that the DS was medically necessary and upheld the decision for the VSG. I'll be sure to document out the yazoo of why I need malabsorption (I think I qualify as suffering from metabloic disorder/Syndrome X) and why the RNY is contraindicated in my case.
MN09-10136 - case is distinguishable because it is from a patient requestion a revision to DS, not virgin bariatric surgery.
MN08-9021: Patient with BMI 42 but no contraindications for RNY. I need NASIDS for several conditions and have history of anemia. So RNY should be deemed contraindicated for ME. Also my starting BMI was over 48 and now despite a loss of over 20 pounds, is still 43.8.
So I sent an email to the surgeon requesting the outside authorization for the DS.
Now waiting for that denial so my appeals process can begin. Perhpas some day, if I have to go all the way up to DMHC, I'll be a MN number too - (Hopefully) one of the many where the insurance company ruling was overturned.
0 comments
I took the weekend to further think about my options and to do a bit of additional research. He said that DMHC will not find the DS medically necessary in Kaiser patients with a BMI below 52 . He said he I can do the appeal process and that DS doctors actually have pamplets on how to do so, but I will be denied all through Kaiser and at DMHC because the DS is not medically necessary - I can have the VSG (even though I need the malabsorption aspect.)
He may have consulted on IMR's in the past, but what may have been true earlier in this century regarding the requirement that a BMI be over 52 for DS approval does not seem to be true any longer. Since the IMR outcomes listed on the DMHC do not specify BMI's for all cases, it makes it difficult to compare with my situation.
What I did find is that most of the cases upholding the insurance company's decision against the DS deal with patients that need revision or wanted other surgeries. From 2008 - present, using the search term Duodenal Switch under the morbid obesity diagnosis category, I found 1 case in 2008 and 2 in 2009. I think I can differentiate my sitiuation from those 3 cases -
MN09-10414 was a patient with a BMI under 50 but they ruled that the submitted evidence did not demonstrate that the DS was medically necessary and upheld the decision for the VSG. I'll be sure to document out the yazoo of why I need malabsorption (I think I qualify as suffering from metabloic disorder/Syndrome X) and why the RNY is contraindicated in my case.
MN09-10136 - case is distinguishable because it is from a patient requestion a revision to DS, not virgin bariatric surgery.
MN08-9021: Patient with BMI 42 but no contraindications for RNY. I need NASIDS for several conditions and have history of anemia. So RNY should be deemed contraindicated for ME. Also my starting BMI was over 48 and now despite a loss of over 20 pounds, is still 43.8.
So I sent an email to the surgeon requesting the outside authorization for the DS.
Now waiting for that denial so my appeals process can begin. Perhpas some day, if I have to go all the way up to DMHC, I'll be a MN number too - (Hopefully) one of the many where the insurance company ruling was overturned.
Back in program without (re)orientation
Jul 06, 2010
Just found out that I have been re-admitted to Fremont bariatric program.
I was patient (for me) and waited almost two whole weeks before calling to find out my status. The nurse called back and now I have a PHONE CONSULT WITH MY SURGEON! (assuming I can get in and get weighed again beforehand so it will be documented in my chart.)
It looks like I got to skip step 2 in my anticipated journey and may soon be on to step 4. Yeah!!!
0 comments
I was patient (for me) and waited almost two whole weeks before calling to find out my status. The nurse called back and now I have a PHONE CONSULT WITH MY SURGEON! (assuming I can get in and get weighed again beforehand so it will be documented in my chart.)
It looks like I got to skip step 2 in my anticipated journey and may soon be on to step 4. Yeah!!!
Step 1: Check
Jun 24, 2010
Had an appointment with my PCP yesterday. He was lovely, as always. I love my PCP - he told me he was sorry I had to wait for him to get back from vacation and sympathaized with my canceled surgery in 2008. He said he totally understood a sudden weight gain on the days right before and during "Aunt Flo's " visit, especially since he knows I seek out salt licks the days before said visit. He was impressed with me toting in my old Bariatric binder and a printoff of the newest version, with highlighting. He took notes when I told him my weight changes over the past year and the dates of my visits. Sure, that is all in my chart but I figured being proactive would strenghten my case and demonstrate my resolve to get some type of bariatric surgery.
Note: I did NOT mention DS to him, nor will I let those two little initials slip from my lips in front of an insurance employee until it is the surgeon.
My PCP is so awesome that after I presented my speal, he congradulated me for being an informed patient and stated that he never wanted to be a barrier to his patients' getting necessary care or referrals. I won't advertise his name because this seems out of character for most PCP's I've seen; they are the gatekeepers, not helpmates. I want to continue having a PCP I love!
He also ordered me to have lab work done, so he can send those results along with the letter of referral. I went in this very morning.
SOOOO - now I'm waiting for lab results and for him to write a letter to my surgeon. Since I'm within 5 pounds of a 'documented weight loss of 10% in the year preceeding" my referral, I'm hoping I'll go directly to surgeon appointment.
*Fingers crossed!*
K.
0 comments
Note: I did NOT mention DS to him, nor will I let those two little initials slip from my lips in front of an insurance employee until it is the surgeon.
My PCP is so awesome that after I presented my speal, he congradulated me for being an informed patient and stated that he never wanted to be a barrier to his patients' getting necessary care or referrals. I won't advertise his name because this seems out of character for most PCP's I've seen; they are the gatekeepers, not helpmates. I want to continue having a PCP I love!
He also ordered me to have lab work done, so he can send those results along with the letter of referral. I went in this very morning.
SOOOO - now I'm waiting for lab results and for him to write a letter to my surgeon. Since I'm within 5 pounds of a 'documented weight loss of 10% in the year preceeding" my referral, I'm hoping I'll go directly to surgeon appointment.
*Fingers crossed!*
K.
My anticipated journey towards WLS, a painfully slow process.
Jun 18, 2010
Step 1: 'Hurry Up and Wait' (HUAW), Pt. 1 portion of my journey - waiting for re-referral from my PCP after an appointment. (ETA - June 24, 2010)
Should the Fates smile on me, and I get to skip "HUAW Pt. 2: The Re-Orientation" I should be sent directly to my former surgeon consult appointment. I'm guessing ETA for that would be late September. At that appointment, I advise that I want the DS and start the fighting/appeal process - step 4.
Step 2: Resistence is futile. Begin "HUAW, Part 2: The Re-Orientation" , I expect 2-3 month delay until once my PCP sends over the request; at least this time I won't have to get shrunk before he can do so. (ETA: late Sept 2010 at the earliest)
Step 3: After re-acceptance and/or re-orientation, HUAW, Part 3 (aka "Call Me!") begins, probably taking 2-4 months before I am given a scheduled appointment with the bariatric team & surgeon. At this appointment, I will demand the DS and be refused. (ETA: Dec. 2010)
Step 4: Fight the Power! Begin my appeal process. My insurance company typically has a 15- 30 day appeal period at the first level. Second internal level will be another 30-60 day delay. If I have to go to the next level with DMHC, I'm guessing that is another 90 day delay. (ETA: April 2011)
Step 6: Referral to DS surgeon.After my Insurance is told that the DS in medically indicated and ordered to cover it, I will then be referred to Dr. Rabkin. I HOPE that there will only be another 1-2 month delay before surgery. (ETA: May 2011)
Step 7: SURGERY!!! (ETA: June 2011)
Step 8: Active Weight loss, up to 12 months to my goal of 160. I expect to have about 7 months of "OMG, I'm melting away" and "Life SOOO rocks!" moments during the weight loss.
Step 9: If my planning is correct, after approximately 7 months I'll then promptly move into the "Anal-rententive Preparation for Reconstructive Surgery Fight " phase. [EST for recon panic - when I have broken the 170 barrier, assuming I actually do lose 95% of my extra weight.]
I anticipate I won't actually be *switched* until sometime next Summer if things go according to my Insurance Co's timeline (i.e., expect delays and fighting)
I hope and I dream of having it done much, much sooner but realize I shouldn't hold my breath! If I'm lucky and things go smoothly (i.e. immediately accepted back into program, directly scheduled to meet with Dr. Dennen, and don't have to go through multiple appeals with Kaiser and DMHC) I could have a surgery date as early as *gasp* January 2011. Which would awesome, totally awesome.
And no, I do not put this out there as a challenge to the Universe.
Kimmie
0 comments
Should the Fates smile on me, and I get to skip "HUAW Pt. 2: The Re-Orientation" I should be sent directly to my former surgeon consult appointment. I'm guessing ETA for that would be late September. At that appointment, I advise that I want the DS and start the fighting/appeal process - step 4.
Step 2: Resistence is futile. Begin "HUAW, Part 2: The Re-Orientation" , I expect 2-3 month delay until once my PCP sends over the request; at least this time I won't have to get shrunk before he can do so. (ETA: late Sept 2010 at the earliest)
Step 3: After re-acceptance and/or re-orientation, HUAW, Part 3 (aka "Call Me!") begins, probably taking 2-4 months before I am given a scheduled appointment with the bariatric team & surgeon. At this appointment, I will demand the DS and be refused. (ETA: Dec. 2010)
Step 4: Fight the Power! Begin my appeal process. My insurance company typically has a 15- 30 day appeal period at the first level. Second internal level will be another 30-60 day delay. If I have to go to the next level with DMHC, I'm guessing that is another 90 day delay. (ETA: April 2011)
Step 6: Referral to DS surgeon.After my Insurance is told that the DS in medically indicated and ordered to cover it, I will then be referred to Dr. Rabkin. I HOPE that there will only be another 1-2 month delay before surgery. (ETA: May 2011)
Step 7: SURGERY!!! (ETA: June 2011)
Step 8: Active Weight loss, up to 12 months to my goal of 160. I expect to have about 7 months of "OMG, I'm melting away" and "Life SOOO rocks!" moments during the weight loss.
Step 9: If my planning is correct, after approximately 7 months I'll then promptly move into the "Anal-rententive Preparation for Reconstructive Surgery Fight " phase. [EST for recon panic - when I have broken the 170 barrier, assuming I actually do lose 95% of my extra weight.]
I anticipate I won't actually be *switched* until sometime next Summer if things go according to my Insurance Co's timeline (i.e., expect delays and fighting)
I hope and I dream of having it done much, much sooner but realize I shouldn't hold my breath! If I'm lucky and things go smoothly (i.e. immediately accepted back into program, directly scheduled to meet with Dr. Dennen, and don't have to go through multiple appeals with Kaiser and DMHC) I could have a surgery date as early as *gasp* January 2011. Which would awesome, totally awesome.
And no, I do not put this out there as a challenge to the Universe.
Kimmie
Here I go again!
Jun 17, 2010
THEN:
I was initially referred to my insurance company's (Kaiser) baratric program in the summer of 2007, after my sleep apnea was confirmed and I was ordered a CPAP machine. I had already had documented co-morbidities of GERD and asthma. Also documented depression, hypothroidism, and pre-diabetic. My BMI at the time was around 44.
10/5/07 - appointment with psychologist to see if I should be referred for WLS.
Late October - accepted into the program and attended orientation in Fremont. Told I had to have a documented 10% weight loss; surgery weight at or below 250. Began severe dieting (Adkins plus low cal!) and working out to jump start loss.
12/28/07: Assorted appointments with staff at clinic plus meeting with assigned surgeon, Dr. Dennen. Since I weighed in within 5 pounds of my surgery weight goal, he said I would be scheduled ASAP. Since my options were RNY and lap-band, I decided on band. Although I'd been lurking on OH, I hadn't been duly dilligent in my research of all surgery types.
5/9/08- pre-surgery appointment: labs and EKG performed. At required surgery weight.
5/13/08: Drove to Fremont and had "last supper" with galpal before we went to hotel for night. Had to be at hospital the following day at 6:00 a.m. I was totally PMSing, so ate lots of salt. (Big mistake - see below)
5/14/08: Surgery day! Friend dropped me off at hospital as directed. Signed pre-op forms and checked in. Given gown to change into, had vital signs taken. I'd gained 10 pounds of water weight due to PMS since prior appointment. Given valium and was waiting on table at 7:30 when surgeon arrived.
Dr. Dennen came to speak with me - advised me he would not perform surgery because of weight gain. Didn't believe that I could gain that much in water weight so quickly. (hello - that's why it is called premenstral bloating! Plus a bariatric surgeon should realize 'bigger' girls have it to the extreme.) He said that my liver would be swollen because of binging (WTF) and that I'd have to wait until I'd lost the water weight before I would be placed back on the schedule pending a surgery date.
Thereafter - I cried for days. Once my period came, my weight dropped 6 pounds overnight and within 2 days of end of period I was back to 'goal' weight. But was told I'd start back at the bus, so to speak, for open surgery date when I called the bariatric program, despite what my surgeon had said about getting me back on the schedule ASAP. Soonest date - months outI spiraled downward in my mood and eating habits. Gained weight, stopped going to the gym, and got further discouraged. Eventually I had not called to checkin with Fremont, and was dropped from the program.
January 2009 - again tried Medifast. Strictly followed it for 3-4 weeks but most of the loss was water gain. Since I wasn't seeing impressive results, I decided to save my money and sanity by being more mindful about my eating.
Started gaining weight like gangbusters after I started eating real food again.
I did check back with the OH boards periodically, but mainly I was discouraged and sad about the options previously offered by my insurance company - RNY or band. Had real doubts about the band because research was becoming available about many patients being unsuccessful and having serious complications. Also with a band - refills for life no longer sounded like a good option. Essentially gave up and continued to gain weight even though I wasn't eating more than a typical normal person.
Summer 2009 - due to my doubts about my insurance permitted options, I decided to put forth renewed effort to lose on my own. Initiatially started eating 1200 calories or less a day. After a few months and pounds, decided that I would permit myself 1-2 free days per month and occassionally would eat up to 1500 calories. Kept my intake in check by using online tools such as FitDay and other tools that provided calorie information.
NOW:
Early 2010. I can't believe I've wasted more years of my life being morbidly obese. Started thinking about getting back on track in March after crazy-busy time; my consideration was on hold until then. I had looked up the current Kaiser bariatric patient booklet and it listed options as RNY, VSG, and Gastric Banding. Came here and did lots of research on these options and looked at published studies. The RNY scared me, especially given that I know several people that had total regain within 4 years and I'd witnessed dumping syndrome first hand. VSG - too new to have long term results. I had realized I DID NOT want gastric banding because of sucky upkeep, complications, and discouraging long term success rate. Didn't know what I wanted but knew I wouldn't be happy with my 3 surgery options. Dedided that the VSG looked better than others but again, worried about long term results; both the band and RNY had great short %EWL but after the honeymoon period major regain was frequent.
May 2010: Cosmic Bitchslap!
I saw an aquaintance at a party and complimented her on her cute outfit. She said it had come from Hot Topic, and my brain glitched hearing Torrid. When I told her she was far too tiny for Torrid, she laughed and said that it didn't use to be the case. I had NO IDEA she had WLS. I'd seen her eat like a "normal" person and thought she one of those blessed with thin genes.
She explained that she had the DS with Dr. Rablin in November of 2007 and had lost 195 pounds. AMAZING!
I told her my failed WLS story and that I'd looked back into Kaiser, but was limited to 3 less than ideal choices. She told me that I could get insurance to pay for the DS - she had successfully done so with Kaiser. She then explained about the DS, life after it, and I was utterly amazed.
After the party, I couldn't believe what I'd learned. I was in shock for a few days. WHY ARE PATIENS BEING PURPOSEFULLY MISLEAD ABOUT
WLS OPTIONS BY THEIR INSURANCE COMPANY???
Late May, 2010: finally joined OH instead of just lurking, partly in an attempt to reconnect with Ms.Kim since I forgot to get her number at the party. Continued researching ALL of my options, including DS. Short term results and people on the VSG board had incredible results, but the DS had excellent long term stats.Began to think it was a dream come true and decided that my guts could be rearranged if medically necessary. Obviously restriction alone was not working because I had lost 20 or so pounds despite low calorie dieting.
Now I'm ready to begin, again. I have an appointment with my PCP for 6/23. I know enough to ask for re-referral but not to mention the dreaded initials DS until I'm with a surgeon trying to work on a surgery date.
I want it done, now. I want to be happy, healthy, confident and 'normal'! I'm totally psyched knowing it can happen within a matter of months if I do get *switched*. I have to remind myself - I've been big my entire adult life. Even when I was at my lowest adult weight and active in sports, I was 170 pounds and considered obese for my 5'6" frame. It took me years to get here, I can get through the required hoops, appeals, etc. and be an improved version of myself by Dec. 21, 2012. Pretty cool to think about.
Kimmie
2 comments
I was initially referred to my insurance company's (Kaiser) baratric program in the summer of 2007, after my sleep apnea was confirmed and I was ordered a CPAP machine. I had already had documented co-morbidities of GERD and asthma. Also documented depression, hypothroidism, and pre-diabetic. My BMI at the time was around 44.
10/5/07 - appointment with psychologist to see if I should be referred for WLS.
Late October - accepted into the program and attended orientation in Fremont. Told I had to have a documented 10% weight loss; surgery weight at or below 250. Began severe dieting (Adkins plus low cal!) and working out to jump start loss.
12/28/07: Assorted appointments with staff at clinic plus meeting with assigned surgeon, Dr. Dennen. Since I weighed in within 5 pounds of my surgery weight goal, he said I would be scheduled ASAP. Since my options were RNY and lap-band, I decided on band. Although I'd been lurking on OH, I hadn't been duly dilligent in my research of all surgery types.
5/9/08- pre-surgery appointment: labs and EKG performed. At required surgery weight.
5/13/08: Drove to Fremont and had "last supper" with galpal before we went to hotel for night. Had to be at hospital the following day at 6:00 a.m. I was totally PMSing, so ate lots of salt. (Big mistake - see below)
5/14/08: Surgery day! Friend dropped me off at hospital as directed. Signed pre-op forms and checked in. Given gown to change into, had vital signs taken. I'd gained 10 pounds of water weight due to PMS since prior appointment. Given valium and was waiting on table at 7:30 when surgeon arrived.
Dr. Dennen came to speak with me - advised me he would not perform surgery because of weight gain. Didn't believe that I could gain that much in water weight so quickly. (hello - that's why it is called premenstral bloating! Plus a bariatric surgeon should realize 'bigger' girls have it to the extreme.) He said that my liver would be swollen because of binging (WTF) and that I'd have to wait until I'd lost the water weight before I would be placed back on the schedule pending a surgery date.
Thereafter - I cried for days. Once my period came, my weight dropped 6 pounds overnight and within 2 days of end of period I was back to 'goal' weight. But was told I'd start back at the bus, so to speak, for open surgery date when I called the bariatric program, despite what my surgeon had said about getting me back on the schedule ASAP. Soonest date - months outI spiraled downward in my mood and eating habits. Gained weight, stopped going to the gym, and got further discouraged. Eventually I had not called to checkin with Fremont, and was dropped from the program.
January 2009 - again tried Medifast. Strictly followed it for 3-4 weeks but most of the loss was water gain. Since I wasn't seeing impressive results, I decided to save my money and sanity by being more mindful about my eating.
Started gaining weight like gangbusters after I started eating real food again.
I did check back with the OH boards periodically, but mainly I was discouraged and sad about the options previously offered by my insurance company - RNY or band. Had real doubts about the band because research was becoming available about many patients being unsuccessful and having serious complications. Also with a band - refills for life no longer sounded like a good option. Essentially gave up and continued to gain weight even though I wasn't eating more than a typical normal person.
Summer 2009 - due to my doubts about my insurance permitted options, I decided to put forth renewed effort to lose on my own. Initiatially started eating 1200 calories or less a day. After a few months and pounds, decided that I would permit myself 1-2 free days per month and occassionally would eat up to 1500 calories. Kept my intake in check by using online tools such as FitDay and other tools that provided calorie information.
NOW:
Early 2010. I can't believe I've wasted more years of my life being morbidly obese. Started thinking about getting back on track in March after crazy-busy time; my consideration was on hold until then. I had looked up the current Kaiser bariatric patient booklet and it listed options as RNY, VSG, and Gastric Banding. Came here and did lots of research on these options and looked at published studies. The RNY scared me, especially given that I know several people that had total regain within 4 years and I'd witnessed dumping syndrome first hand. VSG - too new to have long term results. I had realized I DID NOT want gastric banding because of sucky upkeep, complications, and discouraging long term success rate. Didn't know what I wanted but knew I wouldn't be happy with my 3 surgery options. Dedided that the VSG looked better than others but again, worried about long term results; both the band and RNY had great short %EWL but after the honeymoon period major regain was frequent.
May 2010: Cosmic Bitchslap!
I saw an aquaintance at a party and complimented her on her cute outfit. She said it had come from Hot Topic, and my brain glitched hearing Torrid. When I told her she was far too tiny for Torrid, she laughed and said that it didn't use to be the case. I had NO IDEA she had WLS. I'd seen her eat like a "normal" person and thought she one of those blessed with thin genes.
She explained that she had the DS with Dr. Rablin in November of 2007 and had lost 195 pounds. AMAZING!
I told her my failed WLS story and that I'd looked back into Kaiser, but was limited to 3 less than ideal choices. She told me that I could get insurance to pay for the DS - she had successfully done so with Kaiser. She then explained about the DS, life after it, and I was utterly amazed.
After the party, I couldn't believe what I'd learned. I was in shock for a few days. WHY ARE PATIENS BEING PURPOSEFULLY MISLEAD ABOUT
WLS OPTIONS BY THEIR INSURANCE COMPANY???
Late May, 2010: finally joined OH instead of just lurking, partly in an attempt to reconnect with Ms.Kim since I forgot to get her number at the party. Continued researching ALL of my options, including DS. Short term results and people on the VSG board had incredible results, but the DS had excellent long term stats.Began to think it was a dream come true and decided that my guts could be rearranged if medically necessary. Obviously restriction alone was not working because I had lost 20 or so pounds despite low calorie dieting.
Now I'm ready to begin, again. I have an appointment with my PCP for 6/23. I know enough to ask for re-referral but not to mention the dreaded initials DS until I'm with a surgeon trying to work on a surgery date.
I want it done, now. I want to be happy, healthy, confident and 'normal'! I'm totally psyched knowing it can happen within a matter of months if I do get *switched*. I have to remind myself - I've been big my entire adult life. Even when I was at my lowest adult weight and active in sports, I was 170 pounds and considered obese for my 5'6" frame. It took me years to get here, I can get through the required hoops, appeals, etc. and be an improved version of myself by Dec. 21, 2012. Pretty cool to think about.
Kimmie
