Re: was denied need help!!!

[Guest guest]

Hi ,

Wow, what a coincidence!  I am currently in the appeals process.  I will give you a brief history of myself and my situation:

I am 34 years old with a BMI of 43.9 (5'6" and 275 lbs).  My physician is at South Sacramento Kaiser and although he is my PCP and made the referral he does NOT support this surgery.  He submitted my referral to San Francisco and I don't believe he did it correctly.  I believe he left out very vital information which is why I was denied.  When I questioned him on this, he blamed the poor documentation from my other doctors.  Anyway, my two comorbidities are chronic tendon inflammation in my feet, lower back pain and knee pain and most importantly, a pretty bad case of PCOS (poly cystic ovarian syndrome).  Also, heart disease, diabetes and obesity all run within my immediate family.

I received my letter of denial on 3/15/04 and needless to say, I was devastated.  I went back to my PCP to ask him to help me with the appeal and he pretty much told me no (that's when I found out how truly unsupportive he is).  I went to member services and they, too, were very unhelpful.  All they did was give me a PO box number in Oakland to send my appeal letter (there is no form or format).  This was the same when I called the Oakland 800 number.  The best help I've found so far is within this support group.

I wrote my appeal letter to Kaiser within 30 days of receiving my denial letter.  I tried to stay within the 30 day timeframe because no one at Kaiser was ever able to give me a definite cut off time for my reply.  I wrote in the letter that I did not agree with their decision to deny me.  I gave a breakdown (by paragraph) of my comorbidities and medical history.  I wrote why I thought I should be approved for this surgery.  I wrote very heart felt lines regarding the impact obesity has had on my life and continues to have (i.e., I began dieting at 12 yrs old).  I tried to keep the letter as positive as possible while still drilling my point home.  (Kaiser has to respond to your appeal/grievance within 30 days of receipt of your letter (send your letters certified with return receipt requested!) because this is the law.)

Anyway, my big day is Monday, May 10th.  This is when the Regional Appeals Committee is meeting regarding my case.  Kaiser gives you the option of attending or communicating via telephone conferencing.  They are giving me 10 minutes to speak.  I have outlined a summary of what I'd like to say that I haven't already written in my appeal letter.  I am basically imploring them to reverse the denial and allow me to proceed with this surgery.  I am so nervous!!!!  Anyway, after that, Kaiser has two weeks to let you know their final decision.  If I am denied again, I will take my case to the State Department of Managed Healthcare.  I don't know what that will get me but I'll give it my best shot.

I don't know your age or weight or situation, , but I do know that being obese and unhappy is the same feeling all the way around.  For me it's very frustrating and really drags me down at times.  My feet hurt so bad that there are times I literally can't get up out of bed or out of a chair and walk.  I am only 34 years old!  I can't imagine what I'll be like at 44 or 54 at this rate.  I'm already in so much discomfort.  Believe it or not, it's a struggle to keep my weight at 275.  (I used to be 320 at one point.)  Anyway, good luck with your appeal.  If you'd like some help with your letter, please let me know.  Also, if I wasn't clear on something here or you have a specific question, please let me know!  Good luck to you and hang in there!  Oh, and one more thing - this proved to be very important for me - I will tell you something that someone in this group said to me when I received my denial letter.  It went something like this, "Get ready for the fight of your life.  As a larger person, you may have difficulty standing up for yourself because you've always been put down in the past and may have a low self esteem....don't let the HMO and doctors get you down or get the best of you!"  This operation is a beautiful gift, , and you'll eventually get it - it just might take a little time.  Best of luck to you!  Chanda

[Guest guest]

Chanda:

Best of luck on the 10th. I did not have to go through the appeals process but I had a sister that did. Stand up for yourself and if they deny you again then appeal to the State. My sister was denied by Kaiser's appeal committee but went on to the State and they approved her without a problem (the State is not as strict as Kaiser sometimes can be). Within a week of getting the reply from the State she heard back from Kaiser telling her that they had rethought it and had approved her (they didn't mention that the State had said that she did qualify).

-----Original Message-----From: nelson2229@... Sent: Wednesday, May 05, 2004 10:17 PMTo: gastric-bypass-support-kaiser-patients Subject: Re: was denied need help!!!Hi ,Wow, what a coincidence! I am currently in the appeals process. I will give you a brief history of myself and my situation:I am 34 years old with a BMI of 43.9 (5'6" and 275 lbs). My physician is at South Sacramento Kaiser and although he is my PCP and made the referral he does NOT support this surgery. He submitted my referral to San Francisco and I don't believe he did it correctly. I believe he left out very vital information which is why I was denied. When I questioned him on this, he blamed the poor documentation from my other doctors. Anyway, my two comorbidities are chronic tendon inflammation in my feet, lower back pain and knee pain and most importantly, a pretty bad case of PCOS (poly cystic ovarian syndrome). Also, heart disease, diabetes and obesity all run within my immediate family.I received my letter of denial on 3/15/04 and needless to say, I was devastated. I went back to my PCP to ask him to help me with the appeal and he pretty much told me no (that's when I found out how truly unsupportive he is). I went to member services and they, too, were very unhelpful. All they did was give me a PO box number in Oakland to send my appeal letter (there is no form or format). This was the same when I called the Oakland 800 number. The best help I've found so far is within this support group.I wrote my appeal letter to Kaiser within 30 days of receiving my denial letter. I tried to stay within the 30 day timeframe because no one at Kaiser was ever able to give me a definite cut off time for my reply. I wrote in the letter that I did not agree with their decision to deny me. I gave a breakdown (by paragraph) of my comorbidities and medical history. I wrote why I thought I should be approved for this surgery. I wrote very heart felt lines regarding the impact obesity has had on my life and continues to have (i.e., I began dieting at 12 yrs old). I tried to keep the letter as positive as possible while still drilling my point home. (Kaiser has to respond to your appeal/grievance within 30 days of receipt of your letter (send your letters certified with return receipt requested!) because this is the law.)Anyway, my big day is Monday, May 10th. This is when the Regional Appeals Committee is meeting regarding my case. Kaiser gives you the option of attending or communicating via telephone conferencing. They are giving me 10 minutes to speak. I have outlined a summary of what I'd like to say that I haven't already written in my appeal letter. I am basically imploring them to reverse the denial and allow me to proceed with this surgery. I am so nervous!!!! Anyway, after that, Kaiser has two weeks to let you know their final decision. If I am denied again, I will take my case to the State Department of Managed Healthcare. I don't know what that will get me but I'll give it my best shot.I don't know your age or weight or situation, , but I do know that being obese and unhappy is the same feeling all the way around. For me it's very frustrating and really drags me down at times. My feet hurt so bad that there are times I literally can't get up out of bed or out of a chair and walk. I am only 34 years old! I can't imagine what I'll be like at 44 or 54 at this rate. I'm already in so much discomfort. Believe it or not, it's a struggle to keep my weight at 275. (I used to be 320 at one point.) Anyway, good luck with your appeal. If you'd like some help with your letter, please let me know. Also, if I wasn't clear on something here or you have a specific question, please let me know! Good luck to you and hang in there! Oh, and one more thing - this proved to be very important for me - I will tell you something that someone in this group said to me when I received my denial letter. It went something like this, "Get ready for the fight of your life. As a larger person, you may have difficulty standing up for yourself because you've always been put down in the past and may have a low self esteem....don't let the HMO and doctors get you down or get the best of you!" This operation is a beautiful gift, , and you'll eventually get it - it just might take a little time. Best of luck to you! Chanda

[Guest guest]

Chanda,

Good for you, pressing forward in the appeals process! You should know that cases taken to the Department of Managed Healthcare (DMHC) are approved the majority of the time, as they use National Institute of Health Guidelines and not Kaiser's. They can force Kaiser to pay for your surgery. So you are gonna have that surgery, woman!

Laurie W.

Re: was denied need help!!!

Hi ,Wow, what a coincidence! I am currently in the appeals process. I will give you a brief history of myself and my situation:I am 34 years old with a BMI of 43.9 (5'6" and 275 lbs). My physician is at South Sacramento Kaiser and although he is my PCP and made the referral he does NOT support this surgery. He submitted my referral to San Francisco and I don't believe he did it correctly. I believe he left out very vital information which is why I was denied. When I questioned him on this, he blamed the poor documentation from my other doctors. Anyway, my two comorbidities are chronic tendon inflammation in my feet, lower back pain and knee pain and most importantly, a pretty bad case of PCOS (poly cystic ovarian syndrome). Also, heart disease, diabetes and obesity all run within my immediate family.I received my letter of denial on 3/15/04 and needless to say, I was devastated. I went back to my PCP to ask him to help me with the appeal and he pretty much told me no (that's when I found out how truly unsupportive he is). I went to member services and they, too, were very unhelpful. All they did was give me a PO box number in Oakland to send my appeal letter (there is no form or format). This was the same when I called the Oakland 800 number. The best help I've found so far is within this support group.I wrote my appeal letter to Kaiser within 30 days of receiving my denial letter. I tried to stay within the 30 day timeframe because no one at Kaiser was ever able to give me a definite cut off time for my reply. I wrote in the letter that I did not agree with their decision to deny me. I gave a breakdown (by paragraph) of my comorbidities and medical history. I wrote why I thought I should be approved for this surgery. I wrote very heart felt lines regarding the impact obesity has had on my life and continues to have (i.e., I began dieting at 12 yrs old). I tried to keep the letter as positive as possible while still drilling my point home. (Kaiser has to respond to your appeal/grievance within 30 days of receipt of your letter (send your letters certified with return receipt requested!) because this is the law.)Anyway, my big day is Monday, May 10th. This is when the Regional Appeals Committee is meeting regarding my case. Kaiser gives you the option of attending or communicating via telephone conferencing. They are giving me 10 minutes to speak. I have outlined a summary of what I'd like to say that I haven't already written in my appeal letter. I am basically imploring them to reverse the denial and allow me to proceed with this surgery. I am so nervous!!!! Anyway, after that, Kaiser has two weeks to let you know their final decision. If I am denied again, I will take my case to the State Department of Managed Healthcare. I don't know what that will get me but I'll give it my best shot.I don't know your age or weight or situation, , but I do know that being obese and unhappy is the same feeling all the way around. For me it's very frustrating and really drags me down at times. My feet hurt so bad that there are times I literally can't get up out of bed or out of a chair and walk. I am only 34 years old! I can't imagine what I'll be like at 44 or 54 at this rate. I'm already in so much discomfort. Believe it or not, it's a struggle to keep my weight at 275. (I used to be 320 at one point.) Anyway, good luck with your appeal. If you'd like some help with your letter, please let me know. Also, if I wasn't clear on something here or you have a specific question, please let me know! Good luck to you and hang in there! Oh, and one more thing - this proved to be very important for me - I will tell you something that someone in this group said to me when I received my denial letter. It went something like this, "Get ready for the fight of your life. As a larger person, you may have difficulty standing up for yourself because you've always been put down in the past and may have a low self esteem....don't let the HMO and doctors get you down or get the best of you!" This operation is a beautiful gift, , and you'll eventually get it - it just might take a little time. Best of luck to you! Chanda

[Guest guest]

Hi ,

I was denied twice. The first time my Dr.'s office didn't know how to submit the paperwork and did it incorrectly. The second time my BMI said 43 on some pages and 35 on others pages, so I was denied. My doctor believes in WLS and they took care of everything for me. I didn't have to do anything but I would have done anything I needed to do.

Don't give up, find out what needs to be done and do it. Marina in SF told me why I did not qualify and my doctors office took it from there. I guess I was very fortunate. When I started this process my doctor knew very little about WLS, now he is referring quite a few people for it and says he has learned alot from his patients and has been to seminars and is very supportive after seeing the quality of life so improved in his patients.

Good luck! Carolmichelle wrote:

Has anyone had to go though the appeal?What kind of letter do I write or does my Dr??What if my wt. has changed and my BMI do I just put it on a peice paper and send it off?? Is there a form I fill out?Can someone please give me some input.Thanks