I Fought My Insurance for a DS and Won! (anthem/medi-cal)
Forgive me ahead of time if this is rather long but my journey has been long just to get to this point. I am sharing with all of you to show you that dreams really do come true and that the appeals process really does work. I never gave up fighting and I hope that none of you do, either.
Today I write to you with an array of co-morbidities with only a dream of walking again since I am in a wheelchair at the moment. My age may surprise some of you but co-morbidites and health problems do not discriminate. I am 28 years old. I have high blood pressure, sciatica, type 2 diabetes, edema, asthma, high cholesterol, high triglycerides, symptoms of congestive heart failure, osteoarthritis in several joints, metabolic syndrome, and acid reflux. My current weight fluctuates around 310lbs and I am 5'3" giving me a BMI of 55.
My surgery of choice is the DS for my co-morbidies and it's astounding research on results. I've heavily researched this before jumping into trying to get it, as anyone should.
For the past 4 years I have been really fighting to get approved for WLS. I've had doctors who say that I just need to lose weight and I didn't need bariatric surgery, to ones who said they would refer me just to get denied after supervised diets, to delays from doctor's office staff who failed to submit for 6 months because they are "too busy" and then the issue of insurance denials so many of us are familiar with. But I did not give up. My mother passed away from cancer in the middle of the fight as well, in 2010, and my father passed in 2006 from cancer. My only support was my husband during this process. I have kept it mainly to myself.
I went through several PCPs and found one to refer me. This was the one with the bad staff that delayed. I got into see a surgeon but he didn't perform the DS. He thought I was too high risk as well. I researched and called around to all of the doctors in my state of California who performed the DS and had experience. This left me with Dr. Crookes in Los Angeles; no other doctor would accept anyone that had to do anything with medi-cal (medicaid).
I attended Dr. Crookes seminar and then had my PCP refer me to him. My insurance denied me.
I posted on boards for help and whined a bit here and there. I knew there must be a way. This couldn't just be it. I knew my morbid obesity was killing me and kept trying. Why wouldn't these medical professionals and insurance help me? I certainly didn't want to die.
Two angels from the boards soon contacted me. They told me I should appeal and helped me write a letter. But the appeal was denied due to not medically necessary. These two angels then informed me of a place called the DMHC, a place for people with HMO's here in California to file an external appeal, where basically a third party in charge of regulating HMOs decides who is right.
I submitted a letter requesting an Independent Medical Review (IMR) to them in April with the help of these two angels, along with all of my documentation. I soon got a call saying I had to withdraw my request for an IMR or it would automatically be denied. I guess the only records they had was the first surgeon saying I was too high risk. I requested records from the doctor saying these bad things and saw they did indeed say that about me. I had to dispute this false information so I only had one choice.
I self-paid for a consultation with Dr. Rabkin in San Francisco. He thought I was an excellent candidate. I re-submitted an IMR request in August along with a letter of medical necessity from Dr. Rabkin, a letter from my psychiatrist, and other new medical records, and waited. A week ago I was told it qualified for an IMR. And yesterday I got a phone call from my case analyst at the DMHC. I was approved.
Tears fell from my eyes when she said that one word: approved. I couldn't stop them. Four years of fighting was finally over. I never really thought it would happen as I was so used to getting denied at every direction.
I can proudly say that the fighting was well worth it. I never gave up. And I hope you don't either. The appeals process really works, even for people on medi-cal like me. Now I get the chance to get my life back. I dream of being able to walk again like a normal person. Now I know it is more than just a dream -- it is a soon to be reality.
Thank you for letting me share my story with you all! Never give up!
Today I write to you with an array of co-morbidities with only a dream of walking again since I am in a wheelchair at the moment. My age may surprise some of you but co-morbidites and health problems do not discriminate. I am 28 years old. I have high blood pressure, sciatica, type 2 diabetes, edema, asthma, high cholesterol, high triglycerides, symptoms of congestive heart failure, osteoarthritis in several joints, metabolic syndrome, and acid reflux. My current weight fluctuates around 310lbs and I am 5'3" giving me a BMI of 55.
My surgery of choice is the DS for my co-morbidies and it's astounding research on results. I've heavily researched this before jumping into trying to get it, as anyone should.
For the past 4 years I have been really fighting to get approved for WLS. I've had doctors who say that I just need to lose weight and I didn't need bariatric surgery, to ones who said they would refer me just to get denied after supervised diets, to delays from doctor's office staff who failed to submit for 6 months because they are "too busy" and then the issue of insurance denials so many of us are familiar with. But I did not give up. My mother passed away from cancer in the middle of the fight as well, in 2010, and my father passed in 2006 from cancer. My only support was my husband during this process. I have kept it mainly to myself.
I went through several PCPs and found one to refer me. This was the one with the bad staff that delayed. I got into see a surgeon but he didn't perform the DS. He thought I was too high risk as well. I researched and called around to all of the doctors in my state of California who performed the DS and had experience. This left me with Dr. Crookes in Los Angeles; no other doctor would accept anyone that had to do anything with medi-cal (medicaid).
I attended Dr. Crookes seminar and then had my PCP refer me to him. My insurance denied me.
I posted on boards for help and whined a bit here and there. I knew there must be a way. This couldn't just be it. I knew my morbid obesity was killing me and kept trying. Why wouldn't these medical professionals and insurance help me? I certainly didn't want to die.
Two angels from the boards soon contacted me. They told me I should appeal and helped me write a letter. But the appeal was denied due to not medically necessary. These two angels then informed me of a place called the DMHC, a place for people with HMO's here in California to file an external appeal, where basically a third party in charge of regulating HMOs decides who is right.
I submitted a letter requesting an Independent Medical Review (IMR) to them in April with the help of these two angels, along with all of my documentation. I soon got a call saying I had to withdraw my request for an IMR or it would automatically be denied. I guess the only records they had was the first surgeon saying I was too high risk. I requested records from the doctor saying these bad things and saw they did indeed say that about me. I had to dispute this false information so I only had one choice.
I self-paid for a consultation with Dr. Rabkin in San Francisco. He thought I was an excellent candidate. I re-submitted an IMR request in August along with a letter of medical necessity from Dr. Rabkin, a letter from my psychiatrist, and other new medical records, and waited. A week ago I was told it qualified for an IMR. And yesterday I got a phone call from my case analyst at the DMHC. I was approved.
Tears fell from my eyes when she said that one word: approved. I couldn't stop them. Four years of fighting was finally over. I never really thought it would happen as I was so used to getting denied at every direction.
I can proudly say that the fighting was well worth it. I never gave up. And I hope you don't either. The appeals process really works, even for people on medi-cal like me. Now I get the chance to get my life back. I dream of being able to walk again like a normal person. Now I know it is more than just a dream -- it is a soon to be reality.
Thank you for letting me share my story with you all! Never give up!
I just wanted to congratulate you on being approved for your DS. God is so good. I do want to share with you my experience with the DS. I had my DS surgery 3 mos and 1 wk ago and I have been sick every day since. I am finally knowing what I did wrong and that is protein. Please, please get your protein in. Dont make the same mistake as I did. I was very sick from the anestesia which threw me off. My brother died a week later after my surgery and I was SO SICK!! Get ur protein or u will live in misery all the time. Best of luck to you! I started at 389 on op day and I am at 301 today. God bless you and if u have any questions please dont hesitate to contact me. My name is Melissa.
This is proof that you should never, ever, EVER give up on something you believe in! Best wishes on the rest of your journey!
DenaSee my YouTube vlogs here: http://www.youtube.com/user/LiLtinee
Add me as a friend on Facebook: Dena Waskiewicz
Starting weight: 297 / Goal weight: 140's / Current weight: 138-143
Lap RNY 3/12/2007 ~ Fleur-de-Lis tummy tuck 7/12/2010
Congratulations on getting your approval for the DS. I love my DS, I am 4 months post op and down 75 lbs. I was borderline diabetic, had high cholesterol, could barley walk. I have 2 severly degenerated discs, one in the siatic region and one in the lumbar region. It is easier for me to move now and my cholesterol is down and I am off crestor, and also my diabetic symptoms are gone. blood work normal. You are having the best surgery in my opinion. Good luck to you. Barb
Dr. Jamie Ponce de Leon - Medical guide Laurie Wolf Received money Never showed up - Only thing booked were flights. Surgeon and Medical team, and hospital were awesome . There is another Medical guide named Trish she is good. PM me for info. 
Isn't it the greatest feeling to beat those insurance company *******s???? Especially when you KNOW you're in the right!!!! Congrats and welcome to DS world!!!! It IS worth the wait! OK, YMMV, but, for me... definitely worth the struggle! Good luck with the scheduling part, and keep posting! Mary C
DS Part 1 (VSG) 11/14/06 DS Part 2 12/18/07
HW 430 SW 400 CW 210 GW 170 Blog: lifeisgood-mc.blogspot.com
Congrats on getting approved! It's the greatest feeling in the world to finally have that piece of paper in your hand, proving you were right and they were wrong.
Reading your post, I felt like it could have been written by me 8 years ago. I was denied by my insurance co and appealed first to the insurance company and then through the IMR Board in California. It took forever and I had to write a 40 page letter pleading my case, but they finally approved me.
I had my DS with Dr. Rabkin on 7/14/04 and it was the best thing I've ever done. I went from 356 to 149 and have kept it off +/-5 lbs for the past 5 years. There are definitely bumps in the road, but it is totally worth it!
Let us know when you have a date. I'm rooting for you!
Jen
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