Re: SSF denials-Thanks for the Information!

[Guest guest]

Thank you Laurie!

I had been doubting if to proceed with the appeal, especially since my personal physician seems not to care. When I requested the reason for the decision I also called and requested a copy of his report or an appointment to discuss it (I know I passed the psych), I am still waiting for him also...

I want to thank the group for being there, it has given me a second breath to continue this up hill battle.

Laurie Warner wrote:

"Getting the government involved" would be through the Department of Managed Healthcare (DMHC) in Sacramento. There is a lawyer there who has had WLS himself, and they are *very* good at dealing with appeals. You will definitely have this surgery, and Kaiser will pay for it as mandated through the DMHC, even if they initially deny you.

I wrote quite extensively about this in the past, and I think someone put it into the "files" section. If not, do a search on yahoogroups (our group's posts) for "DMHC" and those posts will come up.

Laurie W.

SSF denials- and me

Hi again everybody. I see I'm not alone in being refused by SSF program. I'm just starting my appeal process. As for D., from what I'm learning in the process certain comorbidities outweigh others . If your BMI is between 40 and 50 you need two, and they must be directly related to your weight. It appears to me that documented low back and knee arthritis as well as hypertension would fit their criteria. These need to go in your appeal. I believe the neck problems hold minimal if any weight, and the foot problem and asthma are considered unrelated to your weight. Are you sure your pmd included all of these in his referral, because I found mine didn't. Also as I'm discovering, if Kaiser declines your appeal, you can get the government involved who mandates the HMOs, and their criteria is a BMI of 40 with no comorbidities. I am just at the beginning of the appeal process like you, and although I'm frustrated at

he slow progress and the time consumed gathering dust (or pounds and diabetis as the case may be), I am confident that eventually one way or another they'll see the light, even if forced by Uncle Sam. I wonder if the problem is they have so many referrals and so little OR time, that they delay some just to give themselves catch-up time. Who knows? Good Luck- Anne

[Guest guest]

HI there,

First, I am so sorry you were denied and have to go through the appeals process. Second, I would recommend that you immediately request a new physician. Way before I considered WLS, I too had a doctor who seemed not to care about me or my health. I only had him for a few months because of relocation, but believe me, I requested a new doc IMMEDIATELY. It is your doctor's job to care about you as a person and if you feel s/he doesn't, your right to request a new doc. The new doc I got is ABFAB and even noticed some irregularities in the tests my previous doctor had run and had them redone. Where my previous doc shrugged off my concern about my rising blood pressure (where previously there had been no problem) the new one noticed it immediately and began monitoring it. Big difference in attitude, let me tell you. I would suggest you share with us where you are so those of us who do have caring doctors can

recommend someone. Whether your appeal is approved or not (which I'm sure it will be) you deserve a doctor who cares about you and your needs.

(Sac) Low wrote:

Thank you Laurie!

I had been doubting if to proceed with the appeal, especially since my personal physician seems not to care. When I requested the reason for the decision I also called and requested a copy of his report or an appointment to discuss it (I know I passed the psych), I am still waiting for him also...

I want to thank the group for being there, it has given me a second breath to continue this up hill battle.

Laurie Warner wrote:

"Getting the government involved" would be through the Department of Managed Healthcare (DMHC) in Sacramento. There is a lawyer there who has had WLS himself, and they are *very* good at dealing with appeals. You will definitely have this surgery, and Kaiser will pay for it as mandated through the DMHC, even if they initially deny you.

I wrote quite extensively about this in the past, and I think someone put it into the "files" section. If not, do a search on yahoogroups (our group's posts) for "DMHC" and those posts will come up.

Laurie W.

SSF denials- and me

Hi again everybody. I see I'm not alone in being refused by SSF program. I'm just starting my appeal process. As for D., from what I'm learning in the process certain comorbidities outweigh others . If your BMI is between 40 and 50 you need two, and they must be directly related to your weight. It appears to me that documented low back and knee arthritis as well as hypertension would fit their criteria. These need to go in your appeal. I believe the neck problems hold minimal if any weight, and the foot problem and asthma are considered unrelated to your weight. Are you sure your pmd included all of these in his referral, because I found mine didn't. Also as I'm discovering, if Kaiser declines your appeal, you can get the government involved who mandates the HMOs, and their criteria is a BMI of 40 with no comorbidities. I am just at the beginning of the appeal process like you, and although I'm frustrated at

he slow progress and the time consumed gathering dust (or pounds and diabetis as the case may be), I am confident that eventually one way or another they'll see the light, even if forced by Uncle Sam. I wonder if the problem is they have so many referrals and so little OR time, that they delay some just to give themselves catch-up time. Who knows? Good Luck- Anne

[Guest guest]

I have just talked to my doctor today! He called me and left a

direct number for a call back after he found out I am filing a

grievance and also that I am requesting access to my medical file.

He spoke to me about his report and he only reported on my most

recent medical care (6 months, so I reminded him of my amenorrhea,

my pain in my left knee, pain in my feet when I get up to walk

(until of course it adjusts to my weight), my car accident with 2

compressed vertebrae, my asthma, and for the first time described to

him the ritual for personal hygiene...not dignified, not pretty and

not without pain (physical and emotional), also urinary incontinence

specially when I go above the 260 lbs. (I oscillate between 250-270

and measure 5'3 " ). He said I could go ahead and write the letter, to

which I responded that I would but that I wasn't looking for his

permission but his support, and I wanted him to help me get the

decision reversed. He said he would make some phone calls, but

reminds me that surgery is no picnic...as if my everyday life was!

So I will keep those of you that are interested posted...

For my education, can someone talk to me about life after...for

example...what is 'dumping', does it interfere with your everyday

life? Can it be controlled?

If those of you who have had the surgery had a chance to go back in

time, would you still go through with it? Any regrets? If so, please

share some of them with me...I would like to see this decision under

all possible perspectives... Thank you all!

And by the way, I live in San Lorenzo, so I am a Bay Area patient

and go to Kaiser Union City.

> " Getting the government involved " would be through the Department

of Managed Healthcare (DMHC) in Sacramento. There is a lawyer there

who has had WLS himself, and they are *very* good at dealing with

appeals. You will definitely have this surgery, and Kaiser will pay

for it as mandated through the DMHC, even if they initially deny you.

>

> I wrote quite extensively about this in the past, and I think

someone put it into the " files " section. If not, do a search on

yahoogroups (our group's posts) for " DMHC " and those posts will come

up.

>

> Laurie W.

>

>

>

> SSF denials-

and me

>

>

> Hi again everybody. I see I'm not alone in being refused by SSF

> program. I'm just starting my appeal process. As for D.,

from

> what I'm learning in the process certain comorbidities outweigh

> others . If your BMI is between 40 and 50 you need two, and they

must

> be directly related to your weight. It appears to me that

documented

> low back and knee arthritis as well as hypertension would fit

their

> criteria. These need to go in your appeal. I believe the neck

> problems hold minimal if any weight, and the foot problem and

asthma

> are considered unrelated to your weight. Are you sure your pmd

> included all of these in his referral, because I found mine

didn't.

> Also as I'm discovering, if Kaiser declines your appeal, you can

get

> the government involved who mandates the HMOs, and their criteria

is

> a BMI of 40 with no comorbidities. I am just at the beginning of

the

> appeal process like you, and although I'm frustrated at he slow

> progress and the time consumed gathering dust (or pounds and

diabetis

> as the case may be), I am confident that eventually one way or

> another they'll see the light, even if forced by Uncle Sam. I

wonder

> if the problem is they have so many referrals and so little OR

time,

> that they delay some just to give themselves catch-up time. Who

> knows? Good Luck- Anne

>

>

>

>

>

[Guest guest]

,

Dumping syndrome happens when foods high in sugar or fat enter the

intestine, causing lightheadedness, crampy abdominal pain, nausea and

vomiting, bloating, a clammy or sweaty feeling and a racing heart.

Some people considered it one of the benefits of Roux-en-Y gastric

bypass because it is a strong incentive against eating the

" wrong "

foods. I am almost 7 months post op and have never experienced it,

but I am still very careful about what I eat. One of the great

benefits of not eating sugar is that fruits taste wonderfully sweet.

Right now, if you gave me the choice of ice cream (with no dumping)

or watermelon, I would definitely go for the watermelon. I wouldn't

worry about dumping. It can definitely be controlled.

As for regrets, my only regret is that I didn't have my surgery

sooner.

Martha Han

> I have just talked to my doctor today! He called me and left a

> direct number for a call back after he found out I am filing a

> grievance and also that I am requesting access to my medical file.

> He spoke to me about his report and he only reported on my most

> recent medical care (6 months, so I reminded him of my amenorrhea,

> my pain in my left knee, pain in my feet when I get up to walk

> (until of course it adjusts to my weight), my car accident with 2

> compressed vertebrae, my asthma, and for the first time described

to

> him the ritual for personal hygiene...not dignified, not pretty and

> not without pain (physical and emotional), also urinary

incontinence

> specially when I go above the 260 lbs. (I oscillate between 250-270

> and measure 5'3 " ). He said I could go ahead and write the letter,

to

> which I responded that I would but that I wasn't looking for his

> permission but his support, and I wanted him to help me get the

> decision reversed. He said he would make some phone calls, but

> reminds me that surgery is no picnic...as if my everyday life was!

> So I will keep those of you that are interested posted...

>

> For my education, can someone talk to me about life after...for

> example...what is 'dumping', does it interfere with your everyday

> life? Can it be controlled?

>

> If those of you who have had the surgery had a chance to go back in

> time, would you still go through with it? Any regrets? If so,

please

> share some of them with me...I would like to see this decision

under

> all possible perspectives... Thank you all!

>

> And by the way, I live in San Lorenzo, so I am a Bay Area patient

> and go to Kaiser Union City.

>

> >

> >