My Insurance Ordeal for the DS

[k9ophile]

What Munchkin said. Your story does help. 1. It shows that with persistence one can get there with the majority of her sanity in tact. 2. Others reading this may be helped in knowing that sometimes it is extremely difficult and if they're having similar struggles, they're not alone.

 

[michelle vasey]

I created this timeline to keep my brains from melting and so that I could pretend that I had any kind of working memory. Seems a waste to have it sit in my DS folder forever unseen. I have scrubbed names and too-personal of information. Feel free to contact me if you have questions.

I have since had my DS surgery (YAY!!) and will be posting about my journey thus far. But until then, here's this bundle of joy:

November 14, 2016 – Met with Kaiser PCP for referral to Bariatric Department

November 15, 2016 – Sleep Study performed (moderate sleep apnea, issued a CPAP)

December 1, 2016 – Met with Kaiser Bariatric Surgeon, Dr. Y

December 3, 2017 – Introduced to Larra and DianaCox through BariatricFacts.org where we started talking, working together to understand my EOC, much advice on how to proceed with Kaiser, and working on a draft of my eventual appeal letter(s). These two wonderful people have kept me on-track and making intelligent decisions and moves for the entire rest of this process

December 8, 2016 – Nutrition Class (2 hours) at Kaiser Bariatric Department

January 17, 2017 – Fluoroscopy / Upper GI Imaging (showed hiatal hernia, distention at distal esophagus, severe reflux)

January 10, 2017 – Contacted Dr. Y regarding waiving the pre-op weight loss requirement, denied, effectively blocking my access to Kaiser psychological evaluation

January 12, 2017 – Contacted Dr. Y regarding authorization for Duodenal Switch, denied

March 15, 2017 – Consult with Dr. Rabkin of Pacific Laparoscopy to determine if I was a candidate for the DS and to start the process with his office

March 16, 2017 – Contacted Dr. Y regarding my consult with Dr. Rabkin, my candidacy for the DS, and asking him to forward my DS request to his superior

March 17, 2017 – Reply from Dr. D, Regional Chair, denying the DS, as reserved for “very very high bmis” based on “no written policy from the physician point of view”

March 23, 2017 – Filed Appeal to Kaiser regarding request to waive pre-op weight loss requirement

March 24, 2017 – Had my bloodwork done. All normal results except for Iron and Ferritin. Supplementing ever since.

April 3, 2017 – Filed follow-up letter to Pre-Op Weight Loss Appeal with additional studies to support my position

April 24, 2017 – Denial letter from Kaiser for Pre-Op Weight Loss Appeal citing that “there are several medical studies that show preoperative weight loss decreases operative time” however these studies were not included or referenced in any way

April 13, 2017 – Finally reached out to PCP regarding fluoroscopy results (from January), Dr. Y not returning my calls for the results, had to go to my PCP

May 1, 2017 – Filed follow-up request from Pre-Op Weight Loss Appeal for the evidence they used in the denial

May 5, 2017 – Phone call with Dr. Hartman for a psychological evaluation

May 12, 2017 – Filed Appeal to Kaiser regarding request for DS procedure with Dr. Rabkin

May 15, 2017 – Denial Letter from Kaiser for the request for studies used to deny my Pre-Op Weight Loss Appeal, stating that the matter was closed and would not receive any follow-up response

June 12, 2017 – Trip to the Kaiser ER for severe pain while eating, diagnosed as GERD

June 14, 2017 – Received Denial letter from Kaiser regarding request for the DS with Dr. Rabkin – stating that “alternative care was available within Kaiser”

June 15, 2017 – Consult with another Kaiser Bariatric Surgeon, Dr. G – said that he didn’t recommend the DS for me either, because Dr. Rabkin was only in it for the money, because I was too young and there is no long-term data on what my liver or bones will look like when I’m 60 years old, and because my BMI “wasn’t that bad”

June 15, 2017 – Received Supplemental Letter from Dr. Rabkin’s Office (that I requested) with his medical opinion of my ER visit. He stated that based on the malformation of my stomach as shown in my fluoroscopy from January, that this was likely a “transient bowel obstruction”

June 19, 2017 – Filed with the DMHC for an IMR regarding authorization for the DS and a re-sleeve of the stomach with Dr. Rabkin, and a hiatal hernia repair.

June 23, 2017 – Received “Revised” Denial letter from Kaiser changing the reason for denial of the Appeal for the DS with Dr. Rabkin from “alternative care was available within Kaiser” to “not medically necessary”

June 26, 2017 – Filed a follow-up letter to the DMHC stating that the Kaiser denial reason had been revised after they rendered their final decision, and after they received notification that I had filed for an IMR, and that this was completely inappropriate and only serves to undermine my entire case

June 29, 2017 – Received call from Anna, a DMHC Claims Adjuster who wanted to clarify if I was filing one request (DS with Rabkin and hiatal hernia repair) or two requests (DS with Rabkin) (hiatal hernia repair). Not certain what the pros/cons would be either way but said two requests

July 5, 2017 – Letter from Kaiser Consultant Mrs. B, acknowledging the submittal of my IMR request to the DMHC, and offering copies of all documentation sent to the DMHC in regards to the IMR

July 11, 2017 – Submitted Authorization form to request copies of all documentation that had been sent to the DMHC in regards to my IMR

July 12, 2017 – Received call from Kaiser Consultant Mrs. B, saying that she can’t do anything with the request for documentation, and that I should send it to the Release of Medical Records Department

July 12, 2017 – Re-submitted Authorization form to Release of Medical Records Department for documentation sent to the DMHC in regards to my IMR

July 18, 2017 – Email from the Release of Medical Records Department saying they have no record of any documents being released to the DMHC, IMR, or MAXIMUS

July 18, 2017 – Emailed Kaiser Consultant Mrs. B, stating that I re-read the letter she sent, and that it clearly directs me to send the request to her and that the Release of Medical Records Department had no records of anything sent regarding the IMR – never received a reply

July 19, 2017 – Filed another follow-up letter to the DMHC stating that Kaiser was constructively refusing my request for the documentation they supplied for my IMR by sending me back and forth, and then ignoring my email and multiple phone calls

July 31, 2017 – Received a UPS Next Day Air package from the Kaiser Consultant Mrs. B, that contained the documents sent regarding my IMR that I had been requesting since the 11th

July 31, 2017 – called my DMHC contact to request a status on my IMR. She said there were some last minute details that had to be worked out and that she would call me back shortly. When she called back, she said that the IMR had upheld Kaiser’s decision, and that any more information would come from the packet they were putting in the mail that day

July 31, 2017 – Cried the rest of the day

August 2, 2017 – Received letter from Kaiser stating the DMHC forwarded my complaints to them about changing the reason for denial after they received notice that I had filed for an IMR, and not providing the documentation they sent in regards to my IMR, saying they will forward my complaint to Regulatory Services Department, and that they did send the requested documents (as of July 31, 2017, and after my IMR was done so I did not get the opportunity to rebut their position)

August 3, 2017 – Received IMR determination letter from DMHC. Stated that they upheld Kaiser’s denial because I was lacking a dietary evaluation and the reviewer was unable to determine if I would have any idea of the risks of surgery, dietary, supplement needs and possible deficiencies of the post-surgery lifestyle

August 3, 2017 – Contacted my PCP for referral to a dietitian

August 3, 2017 – Requested another Supplemental Letter from Dr. Rabkin’s Office detailing his presentation and my understanding of the post-surgery diet, possibility of deficiencies, need for supplementation and follow-up care

August 4, 2017 – Made appointment with Bariatric Department to attend the Nutrition Class again (had been over 6 months since my last one, couldn’t meet with dietitian until I had attended once more)

August 4, 2017 – Authorized (person redacted for privacy) as my Authorized Assistant in relation to talking with the DMHC about my IMR. She sent a letter to her DMHC contact requesting a procedural review because the denial of my IMR was based on a new and unexpected requirement (the dietary evaluation) which was inappropriate at best. DMHC responded that there “may have been some issues” with my IMR and that they were sending it for “quality review” which should be completed in one to two weeks (YAY!)

August 7, 2017 – Second Nutrition Class completed (somewhat bitterly)

August 9, 2017 – Attended a Pacific Laparoscopy (Dr. Rabkin) Support Group in San Francisco for pre-op patients to connect with other pre-op and post-op patients

August 11, 2017 – Appointment with Kaiser dietitian, having sent in food logs for the previous two weeks and an explanation about my frequent vomiting and pain eating and that being the reason my food logs would look odd

August 11, 2017 – Sent follow-up letter to the DMHC with Dr. Rabkins’s second supplemental letter regarding my understanding of the post-DS life and requirements, and the results of meeting with the Kaiser dietitian so that they see I am committed and thoroughly educated on the piece the last IMR reviewer determined lacking

August 14, 2017 – Phone calls from DMHC Clinician, DL, who has misunderstood why the IMR decision was problematic and is trying to get me to figure out what a “baseline micronutrient deficiency test” is, get it done, or find when it was done, and send it to them. Says that they can’t send in for another IMR unless there is a significant change in circumstance or available treatment, but will resubmit under “change in available information” however Kaiser may object because MAXIMUS already adopted their final decision. Says he is there to decide how to move forward and deal with this (with MAXIMUS) and is hoping that Kaiser withheld pertinent information.

August 14, 2017 – Sent DMHC helpline email and DL the blood work test results that were performed by Kaiser in March 2017 as what I understand to be a “baseline micronutrient deficiency test” and that were not included in the documents sent for my IMR

August 14, 2017 – (person redacted for privacy) wrote to her DMHC contact about DL’s apparent misunderstanding of the problems inherent in the MAXIMUS decision, trying to get back on track

August 16, 2017 – Requested a full bariatric blood panel to check ALL nutrient levels.

August 17, 2017 – Sent DMHC helpline email another follow-up email outlining the initial IMR decision and breaking down point by point why it was incorrect. Also some statements about the Dietary Eval not being a barrier to medical necessity determination, etc. Included blood work from March 2017.

August 21, 2017 – Received letter from the DMHC stating that new IMR was in process,

August 22, 2017 – Received results of full bariatric panel, iron and ferritin very low. Kaiser PCP called me to set up IV Iron Infusions. Went in that day for infusion #1 of 5.

August 25, 2017 – Received a call from DL at the DMHC, said he needed to talk with Dr. Rabkin before he speaks with Kaiser to confirm that my low iron and ferritin levels are/are not a barrier to DS surgery. He said that he wanted expert opinion before he spoke with Kaiser so that they didn't say something to the effect of "well she has low iron, so the DS is impossible" and he has no facts to back it up. Dr. Rabkin’s office was closed.

August 25, 2017 – Received a follow-up call from DL at the DMHC, to tell me that Kaiser conceded to another review. They had the opportunity to make a stink about who qualifies for a re-submission but because they failed to submit relevant info they decided not to, he believes. Kaiser also informed him of my new blood work done a week ago, and that they've started me on IV infusions. He asked if I wanted an expedited or standard review, hinting heavily that standard was better to make a fully informed decision. I conceded. He then asked if I wanted to have the re-do submitted now or if I would prefer to wait until my iron and ferritin numbers were improved, and I said submit now because that is an easily correctable thing and should have no bearing on whether or not I meet the threshold of medical necessity. He said it should be submitted early next week.

August 30, 2017 – Iron Infusion #2

September 6, 2017 – Iron Infusion #3

September 13, 2017 – Iron Infusion #4

September 20, 2017 – Iron Infusion #5

October 10, 2017 – IMR Case decision was written as follows: In your case, the independent reviewer determined that the services you requested are not medically necessary. At this time the DMHC cannot require your health plan to provide this service. However, please note, the review state “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.”

October 12, 2017 – Kaiser called me to schedule a Dietary Evaluation with their Nurse TB in South Sacramento Kaiser Bariatric facility, on October 26, 2017.

October 26, 2017 – Met with Kaiser TB for two hours, discussing my knowledge of the DS procedure, my dietary patterns and supplements, as well as family history. She asked me to keep detailed food logs for another week, take new supplements and send her photos of the nutrition information labels.

October 26, 2017 – New recommended supplements purchased on my way home from Dietary Evaluation, emailed TB about the current supplements I was taking, and the new supplements I had integrated into my daily routine.

November 2, 2017 – Food logs submitted, emailed TB regarding when she anticipated the completion of her evaluation report, and what her opinion on my “patient understanding” of the DS and “anticipated patient compliance” would be.

November 2, 2017 – Emailed Dr. D about having had the Dietary Evaluation the previous week, quoted the IMR decision about once done the DS would be seen as medically necessary, and asked about the next steps. Dr. D responded that they had submitted for a re-review of the case since he believes the DS doesn’t resolve GERD, that he would talk to Member Services, and doesn’t know what the next steps are until the re-review is completed.

November 2, 2017 – Contacted DL of the DMHC and asked if Kaiser had submitted any kind of re-review. He said there were no notes in the file and no indication that there was any kind of pending action. He reiterated that the case was closed and not able to alter at this stage, since it was already a re-review of my initial case. He will talk to the DMHC legal team and have someone call me back, because there was some understanding (though it was not communicated in their letter) that once I had the positive Dietary Evaluation, that I would submit an appeal to Kaiser with this new information, and once denied, I would qualify for another IMR for a final final final determination that would require Kaiser to provide this service.

November 2, 2017 – Mailed off CalPERS Administrative Review of my DS request, the IMR decision, and Kaiser’s actions to this point.

November 2, 2017 – Emailed back to Dr. D that I had called the DMHC and that there was no indication of pending action regarding a re-review. Asked him to let me know what Member Services says.

November 13, 2017 – Second Dietary Evaluation performed by Bariatric Dietitian Services and RD Kyle Rose. Passed with flying colors.

November 13, 2017 – Called DL of the DMHC to get a clear answer on my next steps. He said that he spoke with the Assistant Legal Counsel of the DMHC and that she said that there was no need to go through the Kaiser appeals process yet again. That the next step would be to submit a third IMR with the dietary evaluation(s) and that they would give Kaiser five business days to see if they would finally authorize the procedure. However, if they made a stink about it, the worst case scenario would be that it would go through the entire 30-day IMR process.

November 15, 2017 – Received report from RD Rose, included in a third IMR application including a letter explaining my previous two cases, and that this IMR includes the final piece that was preventing approval, the dietary eval. Also included with the letter was the Kaiser eval, my Kaiser eval rebuttal and the new evaluation noting complete understanding of the procedure and anticipated compliance as good.

November 16, 2017 – Spoke with DL again, letting him know that I had filed the third IMR. We chatted about how I was the only one who has ever submitted a third IMR for the same procedure in such a short time frame. It is rare that they get a second submission (not in a negative way toward me, the implication was that this was the issue of Kaiser fighting as hard as they could to not authorize an expensive procedure). I joked that we were all on a first-name basis by now, and he said that he’s actually been presenting my case as one of several that they use in DMHC Case Manager trainings, discussing issues and how to navigate the process. DL also mentioned that in Kaiser’s response, Dr. D expressed grave concerns about my anemia and iron deficiency, and that the DS would only make it worse and was therefore the wrong procedure for me, but later in the same communication said that my anemia and iron deficiencies were “intermittent” which, as DL noted, does not follow as a dire situation that would preclude approval to the DS.

December 1, 2017 – Follow up letter to Kaiser’s position mailed, stating that Kaiser cannot make claims about my “intermittent vitamin compliance” because they have only known me for two years tops, and have never dealt with my twisted stomach issue; that Kaiser’s position that surgery should not even be considered until my iron deficiency is corrected, to which I pointed out my most recent labs showing normal iron and ferratin levels; and that the nutritionist they sent me to had some “serious concerns” but they were about me drinking caffeine which has since stopped and that she have really no idea what she was talking about on the whole.

December 21, 2017 – Call from the DMHC asking if I had a copy of a recent endoscopy that Kasier wouldn’t provide it, and MAXIMUS needed it. I explained I have never had that test, merely a fluoroscopy. This was a day before my third IMR’s due date, and he also explained that they have asked for extension with the outside due date being no later than 45 days.

January 9, 2018 – Received decision letter from third IMR overturning Kaiser’s decision and declaring my request as medically necessary!

January 16, 2018 – Kaiser issued letters for authorization for surgical consultation and for surgery. Many calls were exchanged between myself and Liz McClaren (Kaiser), Dr. O (Kaiser PCP), Dr. D (Kaiser Regional Chair of Surgery), St. Mary’s Hospital, my surgeon’s office, and several others trying to locate the surgical authorization to send to my surgeon’s office, who didn’t receive it until January 23rd. Liz explained that I needed to get my “workup” before she would issue the authorization for surgery, and that she was essentially holding it hostage until then. She didn’t mention that she should be the one to tell me what I needed for this “workup” and that she could and should order and schedule these tests. Thankfully, I didn’t need her after all of that exasperation.

January 23, 2018 – Dr. Rabkin’s office received my authorization for surgery! Scheduled pre-op appointment for Feb 3rd, hospital pre-op appointment for Feb 3rd, and surgery date for Feb 8th!

Wow lady. You have been through it. It makes me feel bad for complaining about the time. You are truly a trail blazer and I hope and pray you are doing well. I hope to hear more from you soon!

 

[Diana S.]

Wow lady. You have been through it. It makes me feel bad for complaining about the time. You are truly a trail blazer and I hope and pray you are doing well. I hope to hear more from you soon!

Ha, I certainly didn’t feel like a trailblazer, I had many moments of “whyyyy are they picking on me!?!” but I knew it was only a matter of time and being a pit-bull about my resolve. Yes, it took me an eternity while I was in it, but looking back I fought the good fight and it was worth it. My story is supposed to help others avoid the time-consuming pitfalls that nabbed me, and hopefully make the journey easier for others.

Meanwhile, if you’re making this decision, it’s for the rest of your life. It’s like when you start driving, and you have a million things to remember and pay attention to and you get super overwhelmed by the enormity of it, but then it becomes routine and you make all your checks and maintenance as a matter of course. But it’s a big deal and you have to commit. Dr. Rabkin told me that this surgery is a commitment between patient and doctor. He does his part, and checks in with you, but you must do your part too. Then we all succeed, including all the rest of us who’ve had the DS and all those fighting the uphill battle to have it too.

In all my thesis-esque research and appeals letters, I found a MOUNTAIN of info about the VSG failing within 5-10 years, and the people that beat themselves up because they thought and/or doctors told them that THEY failed. The VSG was originally part one of the DS, but became separated as a stand alone procedure because of the short-term success. Over time though, it doesn’t work for most and going through a second surgery and fight and all the rest was poopy. I really wish I had known then what I know now.

I am here for you too, and happy to chat about anything you like. I am an open book, especially if it will help someone. And as a note, don’t get upset about DianaCox... she is brutally honest to make sure you are crystal clear. Without her help, and that of Larra, I would not be on this side of the loser’s bench. I have not met more kind, generous and supportive people, and they are worth listening to. If you’re having a disconnect with what’s being said, it’s time to research the heck out of it!

 

[michelle vasey]

Ha, I certainly didn’t feel like a trailblazer, I had many moments of “whyyyy are they picking on me!?!” but I knew it was only a matter of time and being a pit-bull about my resolve. Yes, it took me an eternity while I was in it, but looking back I fought the good fight and it was worth it. My story is supposed to help others avoid the time-consuming pitfalls that nabbed me, and hopefully make the journey easier for others.

Meanwhile, if you’re making this decision, it’s for the rest of your life. It’s like when you start driving, and you have a million things to remember and pay attention to and you get super overwhelmed by the enormity of it, but then it becomes routine and you make all your checks and maintenance as a matter of course. But it’s a big deal and you have to commit. Dr. Rabkin told me that this surgery is a commitment between patient and doctor. He does his part, and checks in with you, but you must do your part too. Then we all succeed, including all the rest of us who’ve had the DS and all those fighting the uphill battle to have it too.

In all my thesis-esque research and appeals letters, I found a MOUNTAIN of info about the VSG failing within 5-10 years, and the people that beat themselves up because they thought and/or doctors told them that THEY failed. The VSG was originally part one of the DS, but became separated as a stand alone procedure because of the short-term success. Over time though, it doesn’t work for most and going through a second surgery and fight and all the rest was poopy. I really wish I had known then what I know now.

I am here for you too, and happy to chat about anything you like. I am an open book, especially if it will help someone. And as a note, don’t get upset about DianaCox... she is brutally honest to make sure you are crystal clear. Without her help, and that of Larra, I would not be on this side of the loser’s bench. I have not met more kind, generous and supportive people, and they are worth listening to. If you’re having a disconnect with what’s being said, it’s time to research the heck out of it!

Thanks Diane. What time is the meeting tonight?

 

[Diana S.]

Thanks Diane. What time is the meeting tonight?

Unfortunately, I am not able to go, because it's a several hour drive and I have a Board Meeting first thing in the morning... but I believe it starts around 6 or 7pm... galaxygrrl, can you clarify for Michelle?

 

[michelle vasey]

Hi all,

I went to the support meeting last night and it was a wonderful experience. So many lovely people and stories. 3 patients with 10 year anniversaries!! Congratulations to the 2 one year anniversaries as well! Thank you to all of you for making me feel so welcome and answering my questions. It was truly inspiring.

I also had my consultation with Dr. Rabkin and walked away feeling empowered and completely confident in him and my choice of procedures. I can't wait to get through this process and schedule my surgery. Here is the latest update:

I have drafted my appeals letter to Kaiser and Diane and Larra are giving me their feedback on it. I can't thank these two enough for their time and attention with their assistance. It is a struggle but really helps to have these experts dedicate themselves to others. I hope I will be able to meet them in person some day.

I will give everyone an update after submission.

All my best,

Michelle

Admin edit for privacy issues

 

[JackieOnLine]

I went to the support meeting last night and it was a wonderful experience.

 

[Zarabear]

It was so great to meet you at the group.
And a big thank you to Diana for assembling your timeline and reliving that long ordeal in the Hope of helping someone else out.

I am so thankful for this board, and Dr. Rabkins group for all the support over the last almost 2 years. I'm a year out and cant believe how far I've come!

I'll be cheering both of you on, every step of the way. ♡♡♡♡

 

[michelle vasey]

It was so great to meet you at the group.
And a big thank you to Diana for assembling your timeline and reliving that long ordeal in the Hope of helping someone else out.

I am so thankful for this board, and Dr. Rabkins group for all the support over the last almost 2 years. I'm a year out and cant believe how far I've come!

I'll be cheering both of you on, every step of the way. ♡♡♡♡

Great to meet

 

[michelle vasey]

Great to meet you too and I would love to keep in touch outside of the forum if you are up for it. Let me know.

 

[Melli]

Wow congratulations this is great

 

[Hiddenrose]

I can tell you that I'm here taking notes in 2024; so your process and agony definitely wasn't an absolute waste of time, though it certainly was unreasonable and abysmal that you had to go through all of that. I've done a few battles with insurance myself; and I don't know if it or receiving dental care are worse.

I got absolute migraines from the run around I got back when I was a 20 year old newlywed whose new husband went through a brain surgery two days after we were married, changing his primary insurance from his parents primary to Medicare primary and then a month later to Medicaid Primary. It was an absolute nightmare; no companies wanted to confirm receiving information from the other and I was at my wit's end to get all those separate bills covered. Everyone pointed fingers at one another denying coverage of the bills saying somebody ELSE was the primary.

I just went through it with insurance for two years trying to get some kind of ADHD treatment/testing - every time I managed (with executive dysfunction issues) to get through one hurdle they would change either who was providing the testing/treatment to whether or not the testing was necessary. This matters because getting treatment for my ADHD symptoms was a big hinge as to whether I could and should have Gastric surgery and have a chance of good outcomes, due to difficulty in untreated ADHD symptoms and 'creating new routines / adhering to schedules' etc.

Now, as I am trying to move toward the SADI, I get to repeat my psych eval I guess because of time lapse and I fully expect to get heat from the insurance company on covering my surgery as it is STILL considered experimental?? After 10 years? I don't understand and posted elsewhere asking about this. I read this forum as it was more recent than the others and I don't know how many of you wise folks are still active on this forum! Your diligence throughout that battle reminds me of my OLD self; and I hope I have the stamina and presence of mind to conduct myself half as well as you have!