DMHC Denial

I just got my letter in the mail today telling me they were "uphelding the health plan's decision" to deny me approval of VSG and agreed with the health plan's alternative options of RNY, VBG, band, biliopancreatic  bypass, biliopancreatic diversion with duodenal switch or laparoscopic bariatric surgery.

Says the plan recommends one of those procedures. It's a good thing I didn't wait for this answer before I started the process for RNY!!

Does anyone know if this mean they will probably most likely approve on the first shot? I know it's hard to tell but they did say it in all of the denial letters I have received that they would, as well as the phone call I made to the person handling my appeal.....

That's a big bummer. I am glad for you though that they ARE covering the other surgeries. Make sure you check out (which I'm sure probably have already) the revision forum too. IMPO stay away from the lapband. I wanted the VSG but everything was/is taking so long before we can submit to insurance that I started thinking about changing my mind to RNY since I know it would get approved with the quickness.

But during this long time of waiting I had the time to reasearch and read up on other procedures. Now I am leaning toward DS since it had the VSG with the switch component which I think I may need some malsorbption. SO If I can get that approved I'll be back on the loosers bench.

I do think that with 1st submission to your Insurance you will get approval since you have all your ducks in a row and meet all the requirements they wouldn't have a reason to deny you! I was approved right away when I had the lapband.

Best wishes.

Thank you. I kind of knew that they would approve the RNY but my surgeon said either VSG or Band and I really don't want the freaking band. He couldn't explain to me why he didn't think I was a good fit for RNY he just said "I don't do that surgery on people like you." Then his office staff says he wrote in my file that I refused the surgery he saw best fit for me because he said he would do the band and refuse to help me get hooked up for RNY. Now my journey has been tainted by the surgeon and not insurance. Insurance said I met their requirements but "seek a covered procedure" back in June of this year. I have to make myself not think about I could have had surgery already if it wasn't for the surgeon in my managed care group! They only had one surgeon so I had to fight the managed care group to let me go outside their group but not outside my insurance's group of covered networks!

Good luck with your revision to DS. I am getting a lot of back lash from some DSers about why I don't want that surgery. It's truly a personal choice and I do think it's a really great surgery and I do believe I can get it approved but I just don't want it!

I can't believe the surgeon said that and didn't have a good reason why and on top of that write in your records you refused the surgery he recommended!!!!! He of all people should know that the lap band is the least successful surgery. Especially those over BMI 35.

Oh, I really hate people who push certain surgeries on people. I am kind of wondering why alot of the DS people do that?? Forget those that are giving you backlash! Only you know what's best for YOU!!

Yeah, try not to think about how long ago you could've had surgery.....Shoood i should have started looking for a revison in 2007. LOL.
But  think of it this way you'll be FINE by summer next year.

Thanks and this is the agrument I gave him for why I was not settling with the band. I told him yes I can follow a diet pretty well, yes I can exercise a little bit, but no I am not settling for the band when I know diabetes is right around the corner! Yes the DS people are a little extreme when you don't want their surgery! I just think the smaller differences in DS and RNY are huge for me and if I did weigh over 300 lbs (I am close I know) I would be going for that one. I hope you get your revision soon.