Reminder: Almost any Californian can get approved for the DS!

Just in case you aren't aware of this -- if you haven't researched the DS, then you don't have all the information you need to make an informed decision about which surgery to have. 

And if you live in CA, it is likely that even if your insurance SAYS they don't cover the DS -- INCLUDING KAISER -- if you want the DS, you can appeal to the CA Dept. of Managed Health Care or the CA Dept. of Insurance, which will overturn denials of the DS in almost every case.  That includes if you want the DS and your insurance says that you have to have a BMI >50 -- you can get that denial overturned as well:

The CA Dept. of Managed Health Care CONSISTENTLY overturns denials of the DS based on BMI <50: http://wp.dmhc.ca.gov/imr/detail.asp?id=8445&optFormat=html& cboDetermination=0&cmdSearch=Search&cboMC=Morbid+Obesity&cbo Treatment2=0&cboDiagnosis2=0&cboDT=0&cboType=0&txtDetails=du odenal

Case Details Reference ID # Type MN08-8445 Medical Necessity Patient Age Patient Gender 59 Male Diagnosis Category Diagnosis Subcategory Morbid Obesity Cardiac Problem Treatment Category Treatment Subcategory General Surgery null IMRO Determination   Overturned Decision of Health Plan   Reviewer's Findings A 59-year-old male enrollee has requested for laparoscopic biliopancreatic diversion with duodenal switch for treatment of his morbid obesity. Findings: The physician reviewer found that there is no scientific evidence which supports the position that patients who have a BMI of less than 50 and have undergone the duodenal switch procedure have done worse than those patients who had a BMI of greater than 50. With the duodenal switch procedure, common and alimentary channel lengths can be tailored for each patient, which in fact makes the procedure more versatile, allowing for greater use of the procedure in a variety of patients.

If you are interested, please come on over to the DS Forum for more information and assistance.

An important reminder to be sure.

I think THIS recent but hardly uncommon decision also points out WHY we fight so hard to help pre-ops be fully INFORMED and, moreover, AVOID the HEARTBREAK of REGAIN and MISERY at having to so RESTRICTIVELY DIET FOR LIFE  that we DS'rs so often see and get privately and publicly messaged from other WLS surgery types years out. How many times have you, I and so many of us who had the foresight and good fortune to choose the DS have gotten tear laden keyboard PMs from post-ops in abject agony seeking a revision to DS?? Not an uncomplicated or without significant risks procedure.

"If only I had known about or thought the DS was even an option." My surgeon never told me about the DS or misled me and even lied about the risks and benefits... "

The Reviewers findings here state what we have known for years, and more importantly, what can be backed by scientifically, peer reviewed LONG and short-term well populated studies.

http://tinyurl.com/5t9brc

"Reference ID #      Type
MN05-4402     Medical Necessity
Patient Age     Patient Gender
54     Female
Diagnosis Category     Diagnosis Subcategory
Morbid Obesity     Hypertension
Treatment Category     Treatment Subcategory
General Surgery     Biliopancreatic Diversion
IMRO Determination      
Overturned Decision of Health Plan      
Reviewer's Findings

The patient is a 54-year-old female who is 5’3” weighing 226 pounds with a body mass index (BMI) of 41. She has comorbid conditions of hypertension, gastroesophageal reflux disease, and degenerative joint disease. She has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery. She is requesting authorization for a duodenal switch procedure. The Health Plan has denied this request and in the alternative authorized Roux-en-Y gastric bypass. Peer-reviewed literature demonstrates duodenal switch has superior long-term outcomes and quality of life compared to Roux-en-Y gastric bypass. In addition, the incidence of weight regain is much higher for patients who undergo Roux-en-Y gastric bypass than those who undergo duodenal switch. Furthermore, there is less likelihood of complications with duodenal switch than with Roux-en-Y gastric bypass. Therefore, I have determined the requested procedure is medically necessary for treatment of the patient’s medical condition. The Health Plan’s denial should be overturned."

Rockne

Just a friendly hello to you.  I hope you didn't eat too much Halloween candy!  Have a great rest of the weekend.

Hugs to you,
      (I just like the way the eyeballs pop out!)

Rockne - You personally saved me the agony of regret by helping me get fully informed about the option and availability of the DS.

Thank you, thank you, thank you
d2k

http://www.obesityhelp.com/forums/CA/board_id,4806/cat_id,44 06/topic_id,3567944/a,messageboard/action,replies/#28119923

 BUMP

Thanks for this post and your continuing dedication to paying it forward. I hope that I will soon be one of those cases you can reference for insurance denials based on BMI < 50. Health Net has until 11/13 to give me an answer to my appeal and then finally I'll be able to get an IMR with the DMHC. After 6 years this is finally going to happen. Too bad the case manager from HN isn't very helpful and will only tell me that my appeal is being looked at by a nurse. Why don't they just deny my appeal and get it over with. Oh how the waiting is killing me.

Good luck.  They are waiting till the last minute cause they think you might just get tired of waiting and just give up or self pay or change to another insurer.  Hang in there.  

 Thanks Dogma. My insurance is in for a surprise. You'd think they'd know I won't go away since I've been insured with them for almost 6 yrs now. My DH has been with them for almost 10. Oh well guess I'll go back to waiting. What a pain in the butt HN is. Can't wait until I can get my IMR with the DMHC.