DHC and IMR

Is anyone familar with the Dept of Health Care and the IMR process? I have Pacificare HMO San Diego, CA and I have been denied twice already for VSG....I would like to know long did it take to hear something from them? Did it turn out in your favor? Anything about this process will be helpful.

 I have info on my page if you are interested. I know that the DMHC has overturned denials of VSG but that is only if there are cir****tances or comorbids that you have that would prevent you from having lapband, RNY or the DS. The VSG is still considered investigational by most insurance companies as well as Medicare. The other 3 procedures are not considered investigational and if you were trying for one of them and meet NIH criteria for WLS then your IMR should turn out favorably.

I qualify for any of them but I was fooled by my Previous Surgeon that he also does the RNY but after being denied for VSG twice I decided to go for the RNY like I had planned but the surgeon wanted to do lap band. I don't want lap band because (no offense to those that chose this surgey) it is a waste of time if you ask me...so now the surgeon is refusing to do RNY on me saying he is saving it for the really sick. I think it's better done on a strong body plus I want something that I know works regardless.

If that surgeon won't do a surgery on you that you qualify for and want, find another surgeon. Your medical group should have more than one bariatric surgeon in their network.

"I think it's better done on a stron body plus I want something that I know works regardless".

Have you thought about getting the DS? The DS has the best stats on excess weight loss, cures type 2 diabetes in 98% of diabetic and doesn't just put it into remission like the RNY does. Right after my DS my high blood pressure and high cholesertol went away. With the DS you have the VSG stomach but you also get the duodenal switch which makes it so you have more malabsorption to help you lose and keep off your excess weight.

I'm almost 7 weeks out from my open DS and am able to eat pretty much anything I want and have already lost 35 lbs. I have had some sugar and don't have dumping. You are less likely to have as much regain with the DS as you would the RNY. If you visit the DS and revision board, here on OH, you'll see plenty of people revising from RNY to DS but not the other way around.

If you are going to be filing a IMR with the DMHC why don't you research your options.  No matter what you decide it's up to you which surgery you should get, you are going to be living with it not your doctor. If the surgeon won't do the RNY on you he's useless. I only have about 130lbs to lose and I was able to get the DS (which my insurance said they only cover on the SMO) so if you want the RNY then you should have it; but if you decide you want the DS you can get that through the DMHC. They are very pro WLS and very pro DS, they have overturned 100% of DS denials. Best of luck to you

I sent in the request for VSG since I was being impatient after 2 denials. But I have started working on a new surgical office and by the time I get everything going I will know by then whether are not I am approved for VSG. If I get approved for VSG then I am going to see how hard it is for the new surgeon to do it. I find it hard to be qualified from one surgeon but the next won't....I know this could happen but I am hoping it doesn't!

Yep... I pushed for the VSG all the way to the IMR level with the DHC only to find out it was the CDI (california department of insurance) that was to review my case. 2 months of waiting... DENIED.  Anthem denied me 3 times including a independant medical review.

Prepare yourself for a long fight.  It is not easy.....

Best

I see you went with the RNY. I am trying to do that as well but the stupid A of a surgeon I had misled me to believe that he does RNY, but when I told him I didn't want to keep pursuing this especially when I see few winning he suggest lap band and I don't want that damn thing for many reasons. So he walked out and here I am at square one again to and found out thru the new surgical group that he would have had to refer me there anyways! I told them I am a very thorough person (at least I try to be) because I don't want to waste time so we could have knicked this in the bud back in March and I could have been down 60 plus lbs by now!

Now I asked and asked back in March do they do RNY before I even knew what VSG was and they lied so I am starting over and it's taking some time since I have to go back to see my PCP that I just saw 2 weeks ago just to explain to him why he need to request all my labs and such before I see the surgeon. Then the letter of denial says yes they believe I meet the requirements for WLS but not for VSG! So i said F it this should be an easy task to get RNY as the letter says see my surgeon for other covered WLS! To my surprise it's not that easy and I can look forward to another 6-8 weeks at least because I have to do a whole lot of stuff for the new surgical office.