Hello all and help with Kaiser!!

[DianaCox]

Is the doctor you contacted a bariatric surgeon or your PCP?

Be prepared - Kaiser is NOT going to refer you to Rabkin, with whom they have a contract to perform the DS (and thus they have to pay him actual money) without a fight. But we know how to fight them.

I believe you can file a grievance over refusing to let you into the bariatric program without losing 10 lbs. That goes immediately to the DMHC after Kaiser denies your grievance.

You can simultaneously request a referral to Dr. Rabkin for the DS, get a denial, self-pay for a consult with Dr. Rabkin (I don't know what he's charging now - I think less than $500), who will almost certainly write a good letter supporting your decision to have a DS, which we can use to file the appeal to the DMHC. That is a longer process, but one you will need in the long run anyway. Your email to this doctor will probably generate the first level denial (although if it was to your PCP, it will likely be forwarded to bariatric surgery, where they will draw out the process by trying to get you into the program and complete their requirements first, and THEN deny your request for a DS) - in your appeal of the denial, we will state the case for why the DS is better for you, that you know they don't provide it, and request the referral to Rabkin. Don't do the self-pay referral until you have a formal denial in writing of your request for the DS, or you won't be able to get reimbursed for it when/if you win the appeal.

You are also going to need to request a special, non-Kaiser-required nutritional consult. This is from a case in which the patient went to Independent Medical Review last year, and the denial was upheld by the IMR reviewer - but the reason was the lack of an evaluation NOBODY ever required before:

“If a dietary evaluation documenting patient understanding of the dietary
restrictions associated with the duodenal switch procedure as well as anticipated
patient compliance is obtained, the requested procedure would be considered
medically necessary.”​

So Kaiser was forced to give the patient this weirdo evaluation, which the patient submitted and the IMR was redone, and the denial was overturned and the DS was approved.

We'll cross that bridge when we come to it. I think you'll have to already be in the bariatric program before you ask for the special consult. Which is of course ridiculous, because Kaiser doesn't do the DS, so how would they know if you were ready for it?

This is going to be a slog - expect at least 6 months.

 

[galaxygrrl]

Well, if the DS is what you want, you really should come to the group and meet us. We don't bite. ;-) And you will get to meet Dr Rabkin without paying the consultation fee. He does about an hour powerpoint of the different surgeries and then, the whole group answers questions for people considering surgery.

 

[michelle vasey]

Great!! The next meeting is on July 11th in SF? How much would it be to just pay for the surgery?

 

[michelle vasey]

Is the doctor you contacted a bariatric surgeon or your PCP?

Be prepared - Kaiser is NOT going to refer you to Rabkin, with whom they have a contract to perform the DS (and thus they have to pay him actual money) without a fight. But we know how to fight them.

I believe you can file a grievance over refusing to let you into the bariatric program without losing 10 lbs. That goes immediately to the DMHC after Kaiser denies your grievance.

You can simultaneously request a referral to Dr. Rabkin for the DS, get a denial, self-pay for a consult with Dr. Rabkin (I don't know what he's charging now - I think less than $500), who will almost certainly write a good letter supporting your decision to have a DS, which we can use to file the appeal to the DMHC. That is a longer process, but one you will need in the long run anyway. Your email to this doctor will probably generate the first level denial (although if it was to your PCP, it will likely be forwarded to bariatric surgery, where they will draw out the process by trying to get you into the program and complete their requirements first, and THEN deny your request for a DS) - in your appeal of the denial, we will state the case for why the DS is better for you, that you know they don't provide it, and request the referral to Rabkin. Don't do the self-pay referral until you have a formal denial in writing of your request for the DS, or you won't be able to get reimbursed for it when/if you win the appeal.

You are also going to need to request a special, non-Kaiser-required nutritional consult. This is from a case in which the patient went to Independent Medical Review last year, and the denial was upheld by the IMR reviewer - but the reason was the lack of an evaluation NOBODY ever required before:

“If a dietary evaluation documenting patient understanding of the dietary
restrictions associated with the duodenal switch procedure as well as anticipated
patient compliance is obtained, the requested procedure would be considered
medically necessary.”​

So Kaiser was forced to give the patient this weirdo evaluation, which the patient submitted and the IMR was redone, and the denial was overturned and the DS was approved.

We'll cross that bridge when we come to it. I think you'll have to already be in the bariatric program before you ask for the special consult. Which is of course ridiculous, because Kaiser doesn't do the DS, so how would they know if you were ready for it?

This is going to be a slog - expect at least 6 months.

Yikes!! I can't handle 6 months. What is plan B? I was depressed about not losing the weight in 6 weeks. So, just so we're clear, if I get the sleeve with Kaiser I cannot get the DS without a 6 month slog? The email I sent was to the bariatric surgeon.

 

[DianaCox]

Um, you are talking to people who may have spent YEARS fighting for and getting their DS. DON'T SAY THINGS LIKE THIS!

The DS is a LIFETIME commitment to a fairly rigid set of requirements for eating style (it's NOT a diet), supplementation multiple times/day, pushing for and tracking a LOT of bloodwork, figuring out how to change your supplements when needed, advocating for yourself in a WIDE variety of medical situation (starting with things like getting iron infusions before you technically are anemic, not allowing everything that may arise medically as being the "fault" of your DS, etc.), and baseline DEXA scans. You are going to have to be a lot more emotionally intelligent than stating you can't handle waiting 6 months. Maybe you ought to read Diana S.'s story. http://bariatricfacts.org/threads/my-insurance-ordeal-for-the-ds.6129/

This is no place to get petulant about fighting the fight, and then accepting a lesser surgery. You are NOT getting a sleeve from Kaiser and then just "adding on" a switch later. Kaiser will NOT pay for your sleeve and then you self-pay for the switch at the same time either. I'm not 100% sure either of these is what you are suggesting, but both of them are ridiculous. You are looking to get a proper DS which includes both the sleeve and intestinal surgery (and cholecystectomy and appendectomy if you still have them) in one procedure.

I am the Bad Cop - I am here to toughen you up. If you can't stand up to this, perhaps the DS is more surgery than you can handle. Get a sleeve, live on a diet for the rest of your life. If you can. However, I note that apparently, you can't handle dieting for 6 weeks - that's a problem.

 

[michelle vasey]

Wow, it seems I really hit a nerve which was not my intention. I will ready Diane's story. I think that DS is what I am looking for and I am ready to fight for it.

 

[galaxygrrl]

Great!! The next meeting is on July 11th in SF? How much would it be to just pay for the surgery?

Yep, July 11th. It's 35K if you pay for it. I went to Mexico and paid 11K. MX is a reasonable choice, although it sounds crazy.

Wow, it seems I really hit a nerve which was not my intention. I will ready Diane's story. I think that DS is what I am looking for and I am ready to fight for it.

Diana keeps people honest, but really, just think this though. The DS is a hell of a lot easier than worrying about dieting every day. Might be a lifetime commitment, but not losing the weight is worse.

 

[DianaCox]

Yup. I am the Bad Cop. I don't want to help kill you. And I don't want people who can't handle the DS, getting the DS, because they get sick and give ammunition to the bariatric surgeons who don't do the DS, to diss the DS and make it harder for people who NEED it and WANT it and should have ACCESS to it, to GET it. I won't knowingly be a party to that.

Many of us think that access to the DS should require an IQ test and an Emotional Intelligence test. The DS is not a toy. There are not very many non-compliant old DSers - they die, or if they're lucky, get reversals before they're too far gone. You are going to have to be assertive, patient, persistent and forceful when necessary. If you can't be, you may wish to reconsider whether you're up the requirements for living with a DS for the rest of your life.

Said by someone amost 15 years out whose labs are great, who ate her protein today and is currently eating warm cherry pie and a cold glass of whole milk for dessert.

 

[michelle vasey]

Yup. I am the Bad Cop. I don't want to help kill you. And I don't want people who can't handle the DS, getting the DS, because they get sick and give ammunition to the bariatric surgeons who don't do the DS, to diss the DS and make it harder for people who NEED it and WANT it and should have ACCESS to it, to GET it. I won't knowingly be a party to that.

Many of us think that access to the DS should require an IQ test and an Emotional Intelligence test. The DS is not a toy. There are not very many non-compliant old DSers - they die, or if they're lucky, get reversals before they're too far gone. You are going to have to be assertive, patient, persistent and forceful when necessary. If you can't be, you may wish to reconsider whether you're up the requirements for living with a DS for the rest of your life.

Said by someone amost 15 years out whose labs are great, who ate her protein today and is currently eating warm cherry pie and a cold glass of whole milk for dessert.

 

[Diana S.]

self-pay for a consult with Dr. Rabkin (I don't know what he's charging now - I think less than $500),

I’m not making any guarantees about today’s prices, but to give an idea, Dr. Rabkin’s consult was $300, his favored (and since retired) psych eval doctor, Dr. Hartman, was $200, and then it was another $60 for an independent nutritional/dietary eval. Money WELL spent and maybe one day refunded. Still waiting for an answer from Kaiser. Not holding my breath.

 

[DianaCox]

Bill Hartman retired?? I don't recall him asking me for permission!! Oh dear, he was wonderful. He did my psych eval over the phone when something happened at the last minute and I couldn't get to him, and needed it for my own appeal, back when the earth was cooling.

Jeeze - and i'm going to be 65 in August. I guess he was possibly a couple years older, but ... not possible! I hope he's having a wonderful time. I imagine he's not really retired, because I don't see him not helping people.

 

[Diana S.]

He actually came to see me in the hospital. I love him to the moon and back! He’s sent me a bunch of hiking and vacation pics and he looks like he’s having a blast. He super-pants deserves it. What a through-and-through amazing man. A couple months later he was at one of Dr. Rabkin’s support meeting groups, so I know he’s still involved. Heck, he could be like my father-in-law who has retired like three times, gets bored and now works with FEMA for disaster relief.

 

[galaxygrrl]

Bill comes to every one of Dr. Rabkin's support meetings. He is still active and still supportive. And yes, who gave him permission to retire. ;-)

 

[JackieOnLine]

Yikes!! I can't handle 6 months. What is plan B? I was depressed about not losing the weight in 6 weeks. So, just so we're clear, if I get the sleeve with Kaiser I cannot get the DS without a 6 month slog? The email I sent was to the bariatric surgeon.

it all sounds extremely frustrating BUT I think you can handle 6 months (and she might be over-estimating so as not to under-estimate) - it just won't be easy. but I think you can.

you deserve what is best for your health.

fight for it! the smart folks here will help and I will use emotions. because that's what I can do.

 

[michelle vasey]

Thanks Jackie. I really needed some encouraging words.

My previous statement was said out of frustration and vulnerability. Being told I am stupid and retarded emotionally was hurtful, although I think it was well intentioned. It certainly gave me pause. That being said and after much more research and soul searching, I am certain the DS is the correct procedure for me. I am only going to do this once and I am willing to fight for it, no matter how long it takes. I am already implementing changes to my diet including eating my protein first in my meals, cutting out caffeine and alcohol and cutting out carbonated beverages.

My bariatric surgeon, Dr. Mostaedi, will be calling me tomorrow in response to my formal request for this procedure. Any words of wisdom regarding this phone call will be greatly appreciated.