Insurance says DS investigational: a how-to manual

(deactivated member)
on 1/31/08 3:15 pm - sunny, CA
(deactivated member)
on 1/31/08 3:22 pm - San Jose, CA
I would take it in to show her, and explain that even if you haven't met the insurance company's requirements, those requirements are wrong, so she should submit for you so you can file a grievance.
M. !!!
on 7/7/08 2:02 pm - CA
On January 31, 2008 at 9:15 PM Pacific Time, DianaCox wrote:
I would ask your doctor to submit your request for WLS NOW (not asking for the DS specifically), and get the denial for lack of doing the six month diet, and appeal.  But instead of JUST appealing through the insurance company's internal review process, after you get the FIRST denial, I would get the forms from the DMHC and file a GRIEVANCE, not a request for IMR, to get them to force Health Net to drop the diet requirement. 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.

...Diana  The link in your quoted message doesn't work :(  Do you have a better link? I am going to UCSF for a consult...so they can deny me. And I just want to have this info on hand. Thanks so much! Maya

My Friends Sarah Ezra and Collette Adams are running a marathon for the Leukemia and Lymphoma Society's Team in Training. They are raising funds to stop Leukemia, Lymphoma and Hogdkin's Disease. They need your support!!!  Please donate!! any amount!!! Thanks!
http://pages.teamintraining.org/sf/nikesf08/sezra   (Sarah's Page)
http://pages.teamintraining.org/sf/nikesf08/cadamsdv8m (Collettes)

THANK YOU!!! Hugs, Maya

(deactivated member)
on 7/7/08 2:07 pm - San Jose, CA
Yeah, for some reason, the DMHC changed the URL a few weeks ago.  Here ya go: http://www.dmhc.ca.gov/aboutTheDMHC/org/boards/cap/Bariatric REV.pdf
blessedandgrateful
on 2/1/08 2:49 am - GA
Diana,   Thanks for this great post!  I have a question about sending the request for the DS.  I am approved for the RNY by one surgeon but must use another to perform the DS.  My insurance company says I must cancel the pre-cert with the RNY surgeon before my new doctor can submit a pre-cert request for the DS.   Should I do this or should I ignore this requirement and send the pre-cert request and letter?  I have never had to navigate these waters with my insurance company and don't want to screw my appeal up.  BTW I have BCBS of MA PPO but live in GA.  I don't know if it makes a difference but it is a self funded account.   Thanks for any imput you have!  Kellie
Tammy_in_PA
on 3/10/08 3:25 am - New Castle, PA
Thank you!!!! That was extremely helpful!
Julie Nolan
on 3/25/08 12:10 pm - RI

Hi, I know I'm late in replying to this post so I'm hoping you get this. Here goes....I have Tricare Prime. It is an entity all it's own. Any suggestions??? Thank you for all your time and effort in helping us all win our insurance's approvals! Jules

71386

For Info about Rhode Island Support Groups, please email me!  [email protected]

(deactivated member)
on 3/25/08 3:00 pm - San Jose, CA

Tricare, I hear, is a *****  All you can do is try -- the more people ask, the more pressure there will be on them to recognize that it SHOULD be offered. You should try to find others who have won with Tricare and get tips from them.

Aimee F.
on 4/9/08 10:06 am - CA
I was approved for Lap-Band of all things, and want the DS. Thanks so much for this - the only reason it was denied is because Dr. Crookes is not contracted with the IPA, although he is a Blue Cross dr. It's soooo lame.

I'm a Type II diabetic taking huge humoungous amounts of insulin - Lap-Band is the worst surgery for me!

I have my consult with Dr. Crookes on Monday and I will hopefully have him write the letter of medical necessity and get this BS out of the way.

THANKS so much for posting this. I've spent the last two hours on the phone with NAMMCAL (the medical managment company who denied my authorization) and Blue Cross, which by the way covers all 3 surgeries, but doesn't specify who gets what in their policy.

UseItorLoseIt
on 4/9/08 10:17 am
My advice is to stay calm (yeah, right!), and appeal and you should win, ESPECIALLY if they approved the LapBand for you -- that's just STUPID. After you get the letter from Crookes, get back in touch with me -- I may be able to help you avoid most of the internal appeal process.
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