Diana S.
Well-Known Member
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
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!
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
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!
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