IMR DENIED

Lori F.
on 11/16/11 4:04 am - Chula Vista, CA

No mechanical failure of my band, despite an EGD that shows esophageal dysmotility. I don't know what I am going to do now...

Pre-band highest weight: 244
Pre-band surgery weight: 233
Lowest: 199 ( for, like, a day)
CW:
260 (yes, with the band!) 
Current Fill: 5cc in 10cc band
BMI: 49
(deactivated member)
on 11/16/11 4:30 am - San Jose, CA
Apparently, the DMHC (or more accurately, their external medical review organization, which I believe is CHDR/Maximus) now has a DS-hating, fatty-hating MD (who knows what this person's qualifications are?) reviewing DS IMRs, and in particular, requests for revision.  See this recent one:

Case Details

Reference ID # Type
MN11-12040 Medical Necessity
Patient Age Patient Gender
31 Female
Diagnosis Category Diagnosis Subcategory
Morbid Obesity Other
Treatment Category Treatment Subcategory
General Surgery null
IMRO Determination  
Upheld Decision of Health Plan  
Reviewer's Findings

A 31-year-old female enrollee has requested duodenal switch revisional surgery for treatment of her obesity status post Roux-en-Y gastric bypass surgery. Findings: The physician reviewer found that there is no evidence of anatomical complication or overt failure of the prior procedure and no dietary or psychological evaluations were provided for review. The patient may require a revision for further weight loss at some juncture, however at this time the clinical necessity of the surgery is not supported with documentation of failure with aggressive dietary and behavioral efforts. It should be noted that even the duodenal switch procedure is not without risks and is merely one tool in an arsenal of weight loss options. This patient was noted to have late weight regain, which is even possible with the duodenal switch procedure. As such, there is no guarantee this patient will not regain weight with the requested procedure unless lifestyle changes including dietary and behavioral modifications are initiated and maintained.
Lori F.
on 11/16/11 4:36 am - Chula Vista, CA
Wow- I've been keeping an eye on the decisions but I've never seen one like this. DAMMIT.
Pre-band highest weight: 244
Pre-band surgery weight: 233
Lowest: 199 ( for, like, a day)
CW:
260 (yes, with the band!) 
Current Fill: 5cc in 10cc band
BMI: 49
Valerie G.
on 11/16/11 4:47 am - Northwest Mountains, GA
Diana is the shiz-nit on this kind of stuff.

Valerie
DS 2005

There is room on this earth for all of God's creatures..
next to the mashed potatoes

Lori F.
on 11/16/11 11:05 am - Chula Vista, CA
Hi Valerie- I'm on it with her! Thanks for the encouragement.
Pre-band highest weight: 244
Pre-band surgery weight: 233
Lowest: 199 ( for, like, a day)
CW:
260 (yes, with the band!) 
Current Fill: 5cc in 10cc band
BMI: 49
ModestoK
on 11/16/11 5:34 am
Lori -
   I am so, so sorry.  I know you must be devastated. 
  Next step - become a total PITA for your insurance demanding seeing a dietitian and therapist weekly, so you can document the hell out of your efforts that you have been compliant.
Then try again in 6 months, or earlier if you have more complications, with additional letters from the therapist, dietitian & your PCP that you HAVE done what is required and that the band failed you.

Kim
Lori F.
on 11/16/11 11:06 am - Chula Vista, CA
Hi Kim- Thanks for the encouragement. GOOD IDEA about being a PITA. I'm already planning... :)
Lori
Pre-band highest weight: 244
Pre-band surgery weight: 233
Lowest: 199 ( for, like, a day)
CW:
260 (yes, with the band!) 
Current Fill: 5cc in 10cc band
BMI: 49
smileyjamie72
on 11/16/11 4:47 am - Palmer, AK

Lori,





Keep your chin up!!!!!
-Jamie

RNY 2/26/2002                           DS 12/29/2011
HW 317                                     SW 263 BMI 45.1
SW 298                                     CW 192 BMI 32.9~60% EWL
LW 151 in 2003  
TT 4/9/2003

Normal BMI 24.8 is my GOAL!!!

 

 

 


 

 

 

GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**

Lori F.
on 11/16/11 11:07 am - Chula Vista, CA
JAMIE- Thanks for the hugs. HOW DID YOURS GO?
Pre-band highest weight: 244
Pre-band surgery weight: 233
Lowest: 199 ( for, like, a day)
CW:
260 (yes, with the band!) 
Current Fill: 5cc in 10cc band
BMI: 49
Renfairewench
on 11/16/11 4:59 am
I'm so sorry. Is there another appeal you can pursue?
 

                   HW (pre RNY) 430 HW (pre DS) 302 / SW 288 /
                          Lowest weight 157 / CW 161
GW 150
                "I'm just one stomach flu away from my goal weight"
                                       
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