NOBODY IN CA HAS TO DO A PRE-OP DIET
I don't frequent this board much, but I just noticed a post about the Kaiser Options program and other pre-op diet requirements, and I want to start a new thread pointing out what Rock did in that thread: the CA Dept. of Managed Health Care has a policy statement, backed up by their IMR/Grievance process, that states that such requirements are improper: http://www.hmohelp.ca.gov/boards/cap/bariatricrev.pdf
If you are told you have to do a pre-op diet, get it in writing, and then immediately contact the DMHC and file a grievance. They will tell your health plan to waive the requirement.
A summary of the DMHC position:
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. Appeal these stupid and unnecessary requirements and make the insurance companies STOP DOING THIS by being a bigger pain in the ass than they want to deal with! If you fight it, you will be helping yourselves, as well as the people who follow in your footsteps! Pay it forward!
Thank you Diana for making mention of this. It's been so long since I won my case against my insurer that I forget there are still people struggling with this.
The insurance companies rely on their members to NOT take the time to appeal. They hope that patients will jump thru all their hoops and eventually decide not to have surgery, saving the insurance company money.
In the state of California, you are first required to make an appeal to your HMO first, then if you are denied you can escalate matters to the DMHC, who by the way is an advocate for the patient. They are the watchdog agency that governs HMOs who operate in California and the mere mention of their name makes HMO's shake in their boots.
My motto in regards to getting approved is "BE YOUR OWN ADVOCATE!" Fight for your health, for the benefits you are entitled to, fight for YOURSELF!!! This is your life, your future, your happiness you are fighting for.
The insurance companies rely on their members to NOT take the time to appeal. They hope that patients will jump thru all their hoops and eventually decide not to have surgery, saving the insurance company money.
In the state of California, you are first required to make an appeal to your HMO first, then if you are denied you can escalate matters to the DMHC, who by the way is an advocate for the patient. They are the watchdog agency that governs HMOs who operate in California and the mere mention of their name makes HMO's shake in their boots.
My motto in regards to getting approved is "BE YOUR OWN ADVOCATE!" Fight for your health, for the benefits you are entitled to, fight for YOURSELF!!! This is your life, your future, your happiness you are fighting for.
Now if you are going to win any battle you have to do one thing. You have to make the mind run the body. Never let the body tell the mind what to do. The body will always give up. It is always tired in the morning, noon, and night. But the body is never tired if the mind is not tired."
- George S. Patton, U.S. Army General, 1912 Olympian
Rita 
Just to further add and clarify to what the illustrious Ms. Cox has already hopefully made clear. This is a grievance procedure that can be filed with CA Dept. of Managed Health Care which is a greatly accelerated process over that of the more laborious external appeal, from both a procedural and mandated time line requirement . Such a grievance procedure is neither rocket science or difficult and can easily be accomplished yourself without a lawyer.
Those not wishing to wade through the earlier link I provided. http://tinyurl.com/42om93, and for those who have chosen the appeals process, the language overturning the health plan's insistence of a diet/nutrition plan looks typically like this:
Reference ID # Type
MN05-4986 Medical Necessity
Patient Age Patient Gender
58 Female
Diagnosis Category Diagnosis Subcategory
Morbid Obesity Hypertension
Treatment Category Treatment Subcategory
General Surgery null
IMRO Determination
Overturned Decision of Health Plan
Reviewer's Findings
The patient is a 58-year-old female with a body mass index of 41.8. She has documented comorbid conditions. She has also been diagnosed with myasthenia gravis. The patient’s primary care provider indicates the patient has been on steroids at times for control of her symptoms. At issue is whether gastric bypass surgery is medically necessary for treatment of the patient’s morbid obesity. With a BMI of 41.8 and comorbid conditions the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that weight loss surgery will be beneficial for this patient. Furthermore, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the best long-term outcome for the obese. Based upon the information provided, weight loss surgery is medically necessary to treat the patient’s morbid obesity. There is concern, however, about the use of steroids for treatment of the patient’s myasthenia gravis. Steroid use can predispose the patient to gastric ulcers, and once Roux-en-Y gastric bypass is performed the stomach can no longer be accessed for examination and intervention if there is a problem. Therefore, the patient’s providers should determine whether the use of steroids would preclude Roux-en-Y gastric bypass in favor of the duodenal switch procedure. As set forth above, I have determined that the requested surgery is medically necessary for treatment of the patient’s medical condition. The Health Plan’s denial should be overturned. Additionally, I could not find a single recent case upholding a health care's denial based upon any diet or exercise requirement pre-op as long as the presenting patient met the nationally accepted criteria for weight loss surgery.
Rock
Those not wishing to wade through the earlier link I provided. http://tinyurl.com/42om93, and for those who have chosen the appeals process, the language overturning the health plan's insistence of a diet/nutrition plan looks typically like this:
Reference ID # Type
MN05-4986 Medical Necessity
Patient Age Patient Gender
58 Female
Diagnosis Category Diagnosis Subcategory
Morbid Obesity Hypertension
Treatment Category Treatment Subcategory
General Surgery null
IMRO Determination
Overturned Decision of Health Plan
Reviewer's Findings
The patient is a 58-year-old female with a body mass index of 41.8. She has documented comorbid conditions. She has also been diagnosed with myasthenia gravis. The patient’s primary care provider indicates the patient has been on steroids at times for control of her symptoms. At issue is whether gastric bypass surgery is medically necessary for treatment of the patient’s morbid obesity. With a BMI of 41.8 and comorbid conditions the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that weight loss surgery will be beneficial for this patient. Furthermore, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the best long-term outcome for the obese. Based upon the information provided, weight loss surgery is medically necessary to treat the patient’s morbid obesity. There is concern, however, about the use of steroids for treatment of the patient’s myasthenia gravis. Steroid use can predispose the patient to gastric ulcers, and once Roux-en-Y gastric bypass is performed the stomach can no longer be accessed for examination and intervention if there is a problem. Therefore, the patient’s providers should determine whether the use of steroids would preclude Roux-en-Y gastric bypass in favor of the duodenal switch procedure. As set forth above, I have determined that the requested surgery is medically necessary for treatment of the patient’s medical condition. The Health Plan’s denial should be overturned. Additionally, I could not find a single recent case upholding a health care's denial based upon any diet or exercise requirement pre-op as long as the presenting patient met the nationally accepted criteria for weight loss surgery.
Rock
Thank you Diana for this post!
I haven't been on this site for quite a while. I was approved by Kaiser conditionally if I could lose 10%. I have stuggeled for years now to lose that weight and just can't do it. I had pretty much given up hope of getting WLS surgery. Your information gives me hope. Also, I have always felt the the DS would be the way to go for me. Now I need to make the resolution to fight Kaiser on both these issues.
~Gail
~Gail R~ high wt.288, surg wt 274, LW 143, CW 153, GW164
Gail I just wanted to give you support...fight girlfriend fight!!
"WLS is only for people who are ready to move past the "diet" mentality" ~Alison Brown
"WLS is not a Do-Over (repeat same mistakes = get a similar outcome.) It is a Do-BETTER (make lifestyle changes you can continue forever.)" ~ Michele Vicara aka Eggface
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