Want a DS, but your insurance says it isn't covered? Even Kaiser?
Then take a look at some of the recent decisions out of the California Department of Managed Health Care. A significant percentage (probably more than half) of these are Kaiser patients, many of whom Larra and I have helped prepare their appeals -- for free, of course. Kaiser says they won't cover the DS, and dismiss it as "experimental" or "too radical" if they even mention it at all in their seminars. But if you want it, and you are lucky enough to live in California, you can get the DMHC (or the CA Dept. of Insurance, which handles PPOs and sends their IMRs to the same reviewers) to overturn your insurance company's denials. If you have an HMO, the insurance company has to pay the ENTIRE cost of your DS with an outside surgeon too.
| IMRO Determination | |
| Overturned Decision of Health Plan |
| Reviewer's Findings |
A 60-year-old female enrollee has requested for a laparoscopic biliopancreatic diversion with duodenal switch for treatment of her obesity. Findings: The physician reviewer found that the scientific literature is clear when it comes to superior long-term outcome of the duodenal switch operation when compared to other procedures. The benchmarks measured include, weight loss, resolution of co-morbidities and lack of any significant differences between their complications when specifics are compared. The duodenal switch operation does not have metabolic side-effects that are worse than that of the gastric bypass operation.In-fact, gastric bypass patients have a higher failure rate and worse nutritional profile long-term than that of the duodenal switch patient. Furthermore, the resolution of diabetes is far superior with the duodenal switch than that of the gastric bypass. |
| IMRO Determination | |
| Overturned Decision of Health Plan |
| Reviewer's Findings |
A 49-year-old female enrollee has requested for a duodenal switch for treatment of her morbid obesity. Findings: The physician reviewer found that there is high incidence of weight regain and inadequate weight loss with gastric bypass. Nutritional deficiencies common after gastric bypass are iron deficiency anemia, protein malnutrition, and poor eating habit secondary to the stricture at the gastro-jejunostomy anastomosis. |
| IMRO Determination | |
| Overturned Decision of Health Plan |
| Reviewer's Findings |
A 54-year-old female enrollee has requested for a laparoscopic biliopancreatic diversion with duodenal switch for treatment of her morbid obesity. Findings: Three physician reviewers found that duodenal switch, open or laparoscopic, is a standard primary treatment for morbid obesity based on available medical evidence and standards within the field. It is endorsed by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS). The vertical sleeve gastrectomy is generally reserved as a staged procedure, as it is yet to be considered a standard primary procedure for morbid obesity. In the 1st ASMBS position statement from 2007, one of the indications for vertical sleeve gastrectomy is for high risk or super obese patients to then be converted later to either the Roux-en-Y gastric bypass or the biliopancreatic diversion with or without duodenal switch. |
(deactivated member)
on 5/23/09 6:07 pm - Vacaytown, HI
on 5/23/09 6:07 pm - Vacaytown, HI
Howdy... fancy seeing ya here :) Hope ya have a great Memorial Day weekend:)
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