how many appeals can you do?

Looks like I have my first appeal letter. Not sure why, how many appeals can you do? Kitty

If you need any help with the appeals process, try contacting Obesitylaw.com.  They fought for me and I got my surgery. Best of luck to you!! Hugs, Heather

Aloha Heather! Just had a thought, have you sent your lawyer a photo of you now ? I bet they would enjoy to see how their hard fight paid off for you...you look amazing and I love your vacation photos.

You don't say specifically WHAT you are appealing. I'm assuming from your profile it might have to do with Health Net's requirement for a weight loss program and getting that underway. You don't need to put up with that nonsense or appeal per se. Rather than "appealing,  consider the getting the forms from DMHC (CA Dept Of Managed Health Care) and file a GRIEVANCE, not a request for IMR, (Independent Medical Review) to get them to force Health Net to drop the diet requirement. This requirement is being overturned almost daily. Here is the DMHC document that establishes that there is no proper basis for requiring a diet: http://www.hmohelp.ca.gov/boards/cap/bariatricrev.pdf SUMMARY CONCLUSION There is no literature presented by any authority that mandated weight loss, once a patient has been identified as a candidate for bariatric surgery, is indicated. There is a mixture of results that question whether weight or truncal obesity is a risk factor for complications after bariatric surgery. The more analytic studies have not found that body mass index (BMI) or total weight is an independent risk factor for complications or death from bariatric surgery. No institution that has recently published data on bariatric surgery describes a protocol requiring weight loss between identification of the need for surgery and the surgery. Many institutions in California have published results of surgery with particular focus on factors that contribute to morbidity and mortality. No paper from a California institution mentions mandated weight loss before bariatric surgery. Nor does any literature regarding the treatment for the morbidly obese recommend continued weight loss during the period between identification of the need for bariatric surgery and the surgery. Mandated weight loss prior to indicated bariatric surgery is without evidence-based support. Mandated weight loss prior to indicated bariatric surgery leaves the patient at increased risk from the patient’s comorbidities. Mandated weight loss prior to indicated bariatric surgery is not medically necessary. Mandated weight loss prior to indicated bariatric surgery would be deviant from the standard of care practiced in the United States and other published countries. The risks of delaying bariatric surgery, while not entirely known in the short-term, are real and can be measured. Any potential value of losing weight prior to bariatric surgery is theoretical and not supported by any data. An experimental study including fully informed consent to determine if there were a reduction in risks or other benefit from mandated weight loss prior to bariatric surgery is indicated. Thanks to my friend D. Cox and reposted for your perusal. It's a virtual certainty you'd prevail and the overturning of the pre-op diet requirement at the a grievance level would also streamline your WLS approval more quickly. You can see these diet requirement overturning decisions yourself http://tinyurl.com/42om93 mixed in with others. Not the least of which are many on the list demonstrating the superiority of short and long-term weight loss and maintaining of same with the Duodenal Switch. If you haven't considered the DS as one of your WLS options please take a look at the recent decisions below: ------------ The patient is a 25-year-old female with a body mass index (BMI) of 37.3 and significant comorbid conditions. She indicates that she has researched all the surgical procedures and has selected the duodenal switch operation for treatment of her obesity. The patient has completed a psychological evaluation and was deemed an appropriate candidate for weight loss surgery. The Health Plan has denied coverage for the duodenal switch surgery asserting that this surgical procedure is not medically necessary for treatment of the patient’s condition. This patient clearly meets the criteria set forth by the National Institutes of Health for surgical treatment of obesity with a BMI of 37.3 and co-morbid conditions. The duodenal switch operation has been shown to be effective for patients with a BMI of less than 50. Additionally, there is no data indicating that nutritional deraignment after the duodenal switch operation is any more prevalent or more serious than what is encountered with the gastric bypass operation. In fact, the lifestyle of patients after duodenal switch is generally free of the ill effects of the gastric bypass, such as the dumping syndrome and intolerance of solid foods. As cited above, there is a large body of scientific evidence available that shows the duodenal switch operation is more durable with a better long-term success rate when compared to the gastric bypass or the Lap Band operation. Based upon the information set forth above, I have determined the requested duodenal switch bariatric surgical procedure is medically necessary for treatment of the patient’s medical condition. The Health Plan’s denial should be overturned. ------------ A 60-year-old female enrollee has requested for laparoscopic biliopancreatic diversion with duodenal switch (DS) for treatment of her morbid obesity. Findings: The physician reviewer found that with a BMI of 43.2 and multiple comorbid conditions, the patient met nationally accepted medical necessity criteria for consideration of weight loss surgery. Peer reviewed articles clearly demonstrate superior weight loss and maintenance of weight loss over the long term with the DS as compared to other surgical procedures. Published data also demonstrates that the Roux-en-Y procedure results in as much, if not more, protein calorie malnutrition as the DS. The patient’s assertion that the DS is the most effective surgical weight loss alternative is well supported in the literature and this option was a medically reasonable approach to surgical weight loss. Psychological, nutritional and cardiology evaluations indicated the patient was an appropriate candidate for the surgery. ---------- Good luck! Rock