Need diabetes or other rare disease.....

My PCP turned in my WLS application and within 10 days I received the big "D"....denied. Honestly....I expected it. Wish I didn't get denied, but expected it. What I didn't expect is that the first and foremost criteria that I did not meet, (nor was part of the criteria last year) is that I need to have diabetes or another rare disease. Rare disease!!???  Shoot....if I had any other rare disease I wouldn't be thinking of WLS!!!! I am just so bummed....I meet, and exceed, the other criteria. But I do not have diabetes....at least, not yet. Nor do I want it! That is one of the reasons why I want the WLS tool.....to get healthier. Can anyone give me some words of advice on how to appeal this? My insurance is Group Health Cooperative and I work for the State of Washington. Thanks, Susan =0/

Hi Paul and thank you for replying to my post. I cannot tell you how frustrating and depressing this whole part of the journey is.  I knew that I would get a denial letter first. It helps weed out the people who are not completely serious about getting WLS. But when I saw the first criteria that I did not have....'diabetes or other rare disease'....I was absolutely floored! Just what exactly do they mean…other rare disease? And I see I am not the only one with that question. How vague can they be?

 

 

Interestingly enough, I went to my monthly WLS support meeting last evening and the bariatric surgeon, himself, came for his once a year visit. He read my denial letter and then read the criteria that PEBB (Public Employees Benefit Board) has for people who work for the State of Washington . He said a number of different times, while shaking his head, how stupid the criterion was and how incredibly vague it was. He in turn said that if I don’t have diabetes he doesn’t quite know how I am going to get approved.

 

 

I know how…I’m going to fight it. Vauge…yes, as well as borderline discriminatory is how I see it. How can they say that one co-morbidity is worth more/better/worse than another? They are all equal and are all because of my obesity and all lessen if not disappear with having WLS.

 

 

Here is the first paragraph of my denial letter:

 

 

Please let me briefly explain how I made this decision. The clinical information submitted for review does not indicate that this patient meets the following PEBB bariatric surgery criteria. While you are over 21 years of age and less than 60 you do not have diabetes or another rare disease that would qualify you for the procedure. In addition there is no documentation of a psychological examination performed by a licensed mental health worker indicating your mental health status or ability to comply with pre-operative requirements and post-operative lifestyle and dietary changes. Also not included in the documentation is an assessment of your pre-operative physical condition or surgical risk assessment by a bariatric surgeon. There is no evidence of participation in a medically structured weight loss program with at least 5%

weight loss that must be maintained up until the time of surgery.

 

 

And below is the PEBB Criteria:

  PEBB Plans The patient must meet all of the following: 1.     Age: Older than 21 an dless than 60 at the time of the procedure

2.     BMI: is equal to or greater than 35 WITH:

            1.  Diagnosis of Diabetes Mellitus OR

         

  2.  Other rare disorders (e.g.: Pseudo tumnor cerebri); in which there is medical evidence that surgery is medically necessary and there is medical evidence the benefits of surgery outweigh the risk of surgical mortality AND

 

            3.     Absence of other medical conditions (i.e.: multiple sclerosis {MS})       that would increase the risk of surgical mortality or morbidity.

 

AND

 

3.     Psychological evaluation:

            1.  Undergo a comprehensive evaluation to assess:

                        *  Mental status or illness

                        *  Ability to comply with pre-op requirements and post-op lifestyle and dietary changes

            2.  Exclude substance abuse or psychiatric illness

            3.  Performed by a licensed mental health worker who has the expertise

 

AND

 

4.   Physical exam:

            1.  Assessment of pre-operative condition and mortality risk, plus contraceptive planning by an internist.  For diabetics, there must be documentation of control.

            2.  Assessment by a surgeon, familiar with bariatric surgery and its risks, ruling out         contraindications to the procedure

 

AND

 

5.  Diet and exercise:

            1.  Must demonstrate active participation in a medically structured 6 month weight loss   program loss of at least 5% of his or her weight during that time period. Weight loss must     be maintained up until the time of surgery.

            2.  Documentation of the weight loss by the practitioner.

 

The Health Plan reserves the right to cancel authorization If the applicant or center does not maintain the above guidelines at the time of surgery. The Health Plan reserves the right to restrict to network practitioners who meet facility requirements.

Authorizations are based on these selective criteria; no prejudicial decisions will be made

 

After the meeting the surgeon told me that if I found an attorney that they would read these and see the challenge in it. I just don’t know where to find an attorney or pay for one for this fight. Do you happen to know of any? Or have any suggestions on how I should fight this fight?

Thanks so much,

Susan

=0)

UGH....sorry Paul for the length of the email. It didn't look that way when I was creating it. I hope you can still get the gist of what I was saying and what was said to me. Susan =0)