Guest guest Posted March 24, 2004 Report Share Posted March 24, 2004 I was denied twice, appealed twice and again denied and finally appealed to the Dept of Managed Health Care in Sacramento. Don't give up--take them to the wall! Are you 100+ pounds overweight? What about high blood pressure, cholesterol, migraines, degenerative joinjt disease, sleep apnea,etc. When you go to the state a doctor who is not affiliated with Kaiser reviews your records and makes a decision that Kaiser is bound to abide by. They go by the National Institute of Health guidelines, which might be a little less strict than Kaisers. You need to have a BMI of 50 with nothing--40 + with two co-mormidities, 35+ with one life-threatening co-morbid. You contact the DMHC through the medical records office by signing a paper to release your records to them and you are contacted in 30 days with their decidion. Let me know if you need any more info. Fran 229/126 below docs goal SSF/Dr. Legha Dec. 11.02 Message: 9 Date: Wed, 24 Mar 2004 05:41:44 -0000 Subject: Denial from Kaiser for gastric bypass I have received a denial letter from Kaiser stating I do not meet the medical criteria for the gastric bypass surgery. When I spoke with the Kaiser nutrionist and my personal physician, they both backed me on my decision to have this surgery and agreed that I did meet Kaiser's criteria to have the surgery (I have PCOS,plantar facitis, chronic tendon inflammation in my feet/ankles, pain in my hips, knees and back). However, in my denial letter it is stating that Kaiser has NO documentation that I was ever treated for the co-morbidities I claim to have and in addition to this, the letter stated I was denied due to my evidence of coverage benefit details (but my insurance is in full effect). I do plan to appeal this but I wanted to speak with someone who has been in the same situation. I am fearful of making the wrong move and getting denied a second time. I have an appt with my dotor on Thursday (3/25) and I will ask for copies of what he submitted to SF and then I plan to request copies of my medical records. I will start the appeal process after I obtain these records. Does anybody have any encouraging comments or suggestions I may follow? ANY ADVICE WOULD BE MUCH APPRECIATED. THANK YOU. ________________________________________________________________ The best thing to hit the Internet in years - Juno SpeedBand! Surf the Web up to FIVE TIMES FASTER! Only $14.95/ month - visit www.juno.com to sign up today! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 25, 2004 Report Share Posted March 25, 2004 Fran, Are the requirements that you listed what Kaiser requires? My research from the NIH website states a BMI of 40 or higher, or a BMI of 35 or higher with 2 co-morbidities. If the NIH has updated their requirements, would you please let me know where you found that information? Thanks! Hugs, Jen ph S Welstand wrote: > I was denied twice, appealed twice and again denied and finally appealed > to the Dept of Managed Health Care in Sacramento. Don't give up--take > them to the wall! Are you 100+ pounds overweight? What about high blood > pressure, cholesterol, migraines, degenerative joinjt disease, sleep > apnea,etc. > > When you go to the state a doctor who is not affiliated with Kaiser > reviews your records and makes a decision that Kaiser is bound to abide > by. They go by the National Institute of Health guidelines, which might > be a little less strict than Kaisers. You need to have a BMI of 50 with > nothing--40 + with two co-mormidities, 35+ with one life-threatening > co-morbid. You contact the DMHC through the medical records office by > signing a paper to release your records to them and you are contacted in > 30 days with their decidion. > > Let me know if you need any more info. > Fran > 229/126 below docs goal > SSF/Dr. Legha > Dec. 11.02 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 25, 2004 Report Share Posted March 25, 2004 In her email, Fran is explaining Kaiser's criteria. The DMHC uses the guidelines as provided by the NIH. That is a person who is 100 lbs. or more overweight with a BMI of 40 or more with no co- morbidities. Just wanted to clarify. > I was denied twice, appealed twice and again denied and finally appealed > to the Dept of Managed Health Care in Sacramento. Don't give up-- take > them to the wall! Are you 100+ pounds overweight? What about high blood > pressure, cholesterol, migraines, degenerative joinjt disease, sleep > apnea,etc. > > When you go to the state a doctor who is not affiliated with Kaiser > reviews your records and makes a decision that Kaiser is bound to abide > by. They go by the National Institute of Health guidelines, which might > be a little less strict than Kaisers. You need to have a BMI of 50 with > nothing--40 + with two co-mormidities, 35+ with one life-threatening > co-morbid. You contact the DMHC through the medical records office by > signing a paper to release your records to them and you are contacted in > 30 days with their decidion. > > Let me know if you need any more info. > Fran > 229/126 below docs goal > SSF/Dr. Legha > Dec. 11.02 > > > Message: 9 > Date: Wed, 24 Mar 2004 05:41:44 -0000 > From: " tballmom1229 " <nelson2229@a...> > Subject: Denial from Kaiser for gastric bypass > > I have received a denial letter from Kaiser stating I do not meet the > medical criteria for the gastric bypass surgery. When I spoke with > the Kaiser nutrionist and my personal physician, they both backed me > on my decision to have this surgery and agreed that I did meet > Kaiser's criteria to have the surgery (I have PCOS,plantar facitis, > chronic tendon inflammation in my feet/ankles, pain in my hips, knees > and back). However, in my denial letter it is stating that Kaiser > has NO documentation that I was ever treated for the co-morbidities I > claim to have and in addition to this, the letter stated I was denied > due to my evidence of coverage benefit details (but my insurance is > in full effect). > > I do plan to appeal this but I wanted to speak with someone who has > been in the same situation. I am fearful of making the wrong move and > getting denied a second time. I have an appt with my dotor on > Thursday (3/25) and I will ask for copies of what he submitted to SF > and then I plan to request copies of my medical records. I will > start the appeal process after I obtain these records. > > Does anybody have any encouraging comments or suggestions I may > follow? ANY ADVICE WOULD BE MUCH APPRECIATED. THANK YOU. > > ________________________________________________________________ > The best thing to hit the Internet in years - Juno SpeedBand! > Surf the Web up to FIVE TIMES FASTER! > Only $14.95/ month - visit www.juno.com to sign up today! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 26, 2004 Report Share Posted March 26, 2004 Okay, now I am wondering something. I have a BMI of 50. Will that make me eligible for the surgery after I go to the nutrition classes for 6 months? I did call Kaiser and got the times for the classes. I want to go as soon as I can drive after my knee surgery a week from today. This group is like a dream come true for me. I have seen a lot of the pictures and am hearing the people talk about all the various aspects of the surgery. I am so fortunate to have this available to me. Thank you so much, Michele > > > I was denied twice, appealed twice and again denied and finally appealed > > to the Dept of Managed Health Care in Sacramento. Don't give up-- take > > them to the wall! Are you 100+ pounds overweight? What about high blood > > pressure, cholesterol, migraines, degenerative joinjt disease, sleep > > apnea,etc. > > > > When you go to the state a doctor who is not affiliated with Kaiser > > reviews your records and makes a decision that Kaiser is bound to abide > > by. They go by the National Institute of Health guidelines, which might > > be a little less strict than Kaisers. You need to have a BMI of 50 with > > nothing--40 + with two co-mormidities, 35+ with one life- threatening > > co-morbid. You contact the DMHC through the medical records office by > > signing a paper to release your records to them and you are contacted in > > 30 days with their decidion. > > > > Let me know if you need any more info. > > Fran > > 229/126 below docs goal > > SSF/Dr. Legha > > Dec. 11.02 Quote Link to comment Share on other sites More sharing options...
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