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IMR Appeals Victory!

Discussion in 'Duodenal Switch' started by Diana S., Jan 12, 2018 at 4:43 PM.

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    Diana S.

    Diana S. Member

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    So I've posted it pretty much everywhere and emailed it to everyone, because at long last I WON MY IMR APPEAL!!!

    To Recap: I'm 35yo BMI of 47, had a sleeve gastrectomy about 12 years ago. Have been having issues vomiting solid food for about a year plus now due to sleeve complications, and I also have sleep apnea and GERD. I was accepted into Kaiser N.Cal's bariatric program but because of the GERD they said it was the RNY or nothing.

    So I appealed... something like December 2016 or January of 2017. Got their denial and started the Dept. of Managed Health Care IMR process. I was denied the first time because I didn't have a DS-specific personal nutritional evaluation... something that was sort-of left field in the area of requirements. We had a re-do that came back as pretty much the same decision, but they made sure to state specifically that once I obtained a report saying I understood the specific nature, problems, required supplements and the likelihood that I will comply with all after-care and supplementation, that the DS would be seen as medically necessary.

    So Kaiser offered me a nutritional eval which came back as a "yes she understands the surgery" but was biased and pretty crummy otherwise. I had an independent agency evaluate me again, and this time got glowing marks. Sent in a THIRD IMR with these reports and finally got my answer:

    YOUR REQUEST IS DETERMINED TO BE MEDICALLY NECESSARY!

    I can't even breathe!

    And now we wait for a minute before I start hassling Kaiser for authorization and get a surgery date with Dr. Rabkin :D

    ENORMOUS thank yous to @Larra and @DianaCox for all your help, support, and talking me off the ledge this past year. I quite literally could not have done this without you!
     
    Last edited: Jan 12, 2018 at 4:49 PM
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    RainCity

    RainCity New Member

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    Susan in Tennessee

    Susan in Tennessee Well-Known Member

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    I'm tickled pink for you, what a hard and bumpy Road you had! My sincere thanks to @Larra and @DianaCox, too, for all the great work you do for this community!
     
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    DianaCox

    DianaCox Bad Cop

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    I must say, her appeals were some of the most stupid and mean-spirited ones Larra and I have seen. We were not going to let Kaiser get away with it. But it was touch and go the whole time! Not fun for Diana S. - and it took an entire frickin' year, and THREE appeals, including getting the DMHC to send it to their lawyers who forced them to do two internal re-reviews, so more like FIVE appeals. Emotionally exhausting.
     
    JackieOnLine and Diana S. like this.
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    galaxygrrl

    galaxygrrl Well-Known Member

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    So happy for you! Shout out to @DianaCox and I assume @Larra

    You should come to group next month. :)
     
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    southernlady

    southernlady Administrator Staff Member

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    Munchkin

    Munchkin Full of Fairy Dust

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    hilary1617

    hilary1617 First time at the rodeo.

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