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.

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About Me
29.2
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DS
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01/18/2011
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May 19, 2010
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