Updates on CA Reconstructive Surgery Legal Battles

To recap: I am fighting with Health Net on two fronts, both of which will set the stage for future actions against other insurers in CA.  The issue is a never-enforced 1999 CA statute that mandates coverage for reconstructive surgery for patients having “abnormal structures of the body” “caused by a disease” for whom reconstructive surgery can “improve appearance to the extent possible” and where that improvement is “more than minimal” – with NO REQUIREMENT FOR MEDICAL NECESSITY for surgery.  This is exactly the situation most of us who have been MO have after massive weight loss

 

In the DMHC: I won my grievance back in December, arguing that HN’s denial of my request for pre-certification based on lack of medical necessity was illegal.  The DMHC ordered HN to pre-certify my surgeries, and HN REFUSED.  The Enforcement Division of the DMHC has instituted an audit of HN’s records, which is currently underway.  Also, the DMHC has instructed their Independent Medical Review contractors (CHDR) about the CA law, and they will NOT uphold a denial based on lack of medical necessity.  This is not yet reflected in the DMHC decisions posted on their website, but not that many people appeal, because the plastic surgeons tell them it won’t do any good.  I anxiously await seeing the results of the first application of this new policy.

 

In my class action lawsuit: there was a hearing yesterday (5/16) on HN’s motions to have the lawsuit dismissed or stayed.  They tried to argue that (1) I had no damages to recover, because I haven’t had surgery (!!), and (2) that since the DMHC (the regulatory agency that controls them in CA) is investigating their treatment of patients requesting reconstructive surgery (see above), there is no need for the class action suit.  Of course, both of those arguments are ridiculous – the class action suit is not a regulatory action, it is a suit for unfair competition, and we are trying to get not only compliance with the law in the future, but reimbursement for anyone who has been denied coverage since 1999.  From what I understand, everything went our way in the hearing, except the judge wants an amended pleading showing why past harms (to people who went ahead and self-paid after getting denied) can be addressed by this suit.  Most importantly, the judge ordered written discovery, which means HN is now going to have to do a whole bunch of really annoying and expensive work to produce documents and medical records of everyone *****quested reconstructive surgery for the last 9 years, which will amply demonstrate their failure to comply with this law.  Pardon me if I enjoy this thought just a little bit!

 

If you are contemplating reconstructive surgery, please contact me by PM with your email address, and I will send you a template letter for your plastic surgeon to personalize to your case for submitting to the insurance company – it tracks the language of the CA statute and makes it easier for the DMHC to overturn any denials.  I will also send you a copy of the document the DMHC is using (a “TAG”) as a guide for the audit of the insurance companies – it was supposed to be a confidential document, but Health Net submitted it in my class action suit to try to get the judge to dismiss the suit, so now it is available to anyone to see how the DMHC is interpreting the statute!

Mu WL surgery in June 6, and I anticipate needing a tummy tuck eventually.  Had assumed I'd have to pay.  Thanks for all your hard work.  I would appreciate anything you could send to me; template for letter and any documents.  I had Health Net refuse an insulin pump for my daugher many years ago.  Had to fight hard but got it covered.  Then they denied the insulin pump sets, saying one did not guarantee the other, ya, right.  Won that one too.    Fern

You have to send me a PM with your email address.  But it may be more than a little early for you to worry about this yet.  Things will probably change a LOT by the time you are ready.

Sounds good.  Many thanks.   Fern

Hi Diane,

I am only 4 months out, but am actively following your case. If I can help at all, please let me know.

Good luck!

That is so great for you!!!!! Way to fight!! So what exactly are you trying to get covered? I can get my insurance to cover my panni removal but I really need something done with my backside. I am in so much pain from the excess skin around my tailbone. It bunches up sometimes and leaves bruises. I have not been able to get approval for anything there. Michelle in SoCal

* Lower body lift (circumferential)  including    -- lipo of my upper abdomen   -- abdominal muscle tightening   -- lipo of hips, inner thighs and saddlebags (I have heavy fat deposits there) prior to the inner thigh and butt work * Reduction mastopexy (HN actually approved that, but I didn't want a single procedure -- I want it combined with the brachioplasty at least) *  Brachioplasty, with extension to the breast incision to remove the "side boobage" *  Inner thigh lift and inverse butt lift And, while I'm at it, 30 years ago I had my right submandibular salivary gland removed because of sialolithiasis (a disease!) -- after massive weight loss, the asymmetry of my face is now apparent (as is my sagging post-weight loss wattle).  I think THAT might fall under the statute too.

I need alot of work done a full body lift arms chest I'm interested in this since it my same insurance Please send me the info

As I said in my post, you have to PM me with your email address.