Question:
Can anyone tell me more about Kaisers approval process?

I would like to email with anyone who is going through approval process with Kaiser? I'm with Kaiser Northern California (San Francisco) and would love to hear from anyone who has been through the approval process or is currently going through it. Am also looking for a complete list of what Kaiser considers co-mobidities. Especially interested in whether fibromyalgia is considered. Thanks, Joy    — [Deactivated Member] (posted on March 18, 2001)

March 18, 2001
In response to your question, I can offer the following advice pertaining to California Insurances All insurance carriers and medical groups "IPA" use an industry guidelines entitled "Interqual Criteria" THE INTERQUAL CRITERIA STATES THAT THIS TYPE OF PROCEDURE MUST BE REVIEWED BY MEDICAL DIRECTOR. THE MD REVIEWER MUST GIVE SPECIFIC INFORMATION FOR THEIR DECISION FOR DENIAL."NO MEDICAL DOCUMENTATION OF WT LOSS ATTEMPTS, CLINICAL MEDICAL HISTORY". Kaiser is known for their denial process for any medical requests. Your best approach is to APPEAL.. According to California laws, you have the right to appeal your denial within 60 days. In your initial denial letter, Kaiser must give specific medical criteria to justify the denial. Follow the appeal guidelines timeframe and write a letter requesting an appeal. Your appeal letter must include medical justification why you must be reconsidered for this surgery..... Current weight, past medical interventions to lose wt and duration of diet programs, current medical problems, ie fibromyalgia,.... The healthplan and or IPA must respond within the guidelines. Be sure to send all your information certified and registered mail. If your research the website for Department of Health {DHS} guidelines these will enable to appeal.... If in the event, Kaiser does not approve your request for surgery in the appeal process. File an appeal requesting a state review the Department of Managed Care... Good Luck, Lani
   — lani P.

March 18, 2001
I live in San Jose and have Kaiser of No. Cal. I had no problem being referred by my PCP...but that is where the good times stopped. From there I did get to see a "behavioral therapist", which was like a shrink exam most doctors ask for. That is where I became dead ended. I was then informed that I would have to attend a year long diet class, one that teaches nutriution and dieting skills...I refused..at 50 years old and sitting at a BMI of 52...I straight out told them that I would NOT waste another year of my life at a class. I might have considered it but then I was told after attending the class...I would have to be approved or denied by a medical review board. I personally didn't feel like dealing with them and all their stall tactics. Luckily I was able to self pay for this surgery and did so with a wonderful doctor in Pleasanton, Ca. I found kaiser to be frustrating, and people very ill informed. I could never get any questions answered as each peson I dealt with only knew "their job" and nothing beyond that. In fact..the person who tried to set me up for the year long classes straight out told me that Kaiser is all about saving money. Stalling people for this surgery is one way of doing it and then having the medical review board deny you. I sincerely hope you have better luck than I did. I tried for 8 months to get somewhere with my Kaiser here in San Jose and I have to tell you...it was a waste of time. Good luck to you.
   — leslie F.

March 19, 2001
I have been dealing with Kaiser Santa Teresa for 8 months. In the last 3 months, since my refferal was sent to Kaiser South San Francisco, I have also been dealing with them and thats were the headaches really begin. You will have to get your PCP (Personal Care Physician to agree with you that you need this operation. You will then have have a Phsyciatric evalution, you will have to have a dietary evaluation and at that point they will want you to take weight management classes. I refused and I know many others have too. I have been on every diet imaginable and could teach the class myself...it is only a waste of my time and delaying the referral being sent to Kaiser South Santa Teresa. If you don't already have medical records documenting your comorbities you will have to go through that process. I had documentation regarding my high blood pressure, but I needed X-rays for my back taken, and they will want you to take sleep apnea testing (the surgeons on the committee for approval, 8 of them will kick back your referral until you complete that testing. Once your referral goes to Kaiser S. San Francisco a young lady by the name of Marina will make sure all the paperwork required is in the referral and she will send it to the 8 differant surgeons. She does this every monday. If all 8 surgeons agree on approval you have no problems, by I know from experience and talking to others it does not always go that smoothly. All along the way it seems they put walls in your way to delay this. The answers to any of your questions are lacking in directness and consistancy. Below are names of people of have talked to and even though I have received very little to no help at least I can make complaints regarding the way this department treats their patients. Nadia Hanson-Bariatric program Manaager- Kaiser S. San Francisco Marina - Nadia's assistant Mel - Patient advocates office ( a contradiction of term)
   — Terilyne M.

November 5, 2002
HI, I have dealt with Kaiser Northern Ca for about 7 1/2 months now. I am approved and have gone down to San Diego for my pre-ops.They dish you out to San Francisco or San Diego. It is nice down in SD. Kaiser even pays for your airfaire(two seats) and your hotel. I am now just waiting for the surgery date. Which should be within the next 6 weeks. Yessssssss... As for co-morbidities. I have Diabetes,blood pressure, two bad legs(foot disease) thyroid. Shortness of breath. joint ache. Just think of any and everything you have documented. I am sure that fibromyligia is among the list. Another thing when dealing with them. When they say to wait 60 days. DON'T!!! Call them after a couple weeks telling them you would just like to see how things are going and want to make sure they have all the paperwork. Another trick if you want to be a little faster. Go to a Pacific Bariatric Seminar in your town. They have them there too. Kaiser just may dish you out to them. You do not know till the last minute. That way you are totally fixed up with them already too.Besides you may get in faster. If you have any questions feel free to email me. Bye...good luck
   — Theresa B.