Research
The road to getting surgery, for me, wasn't as easy as most. I started the steps in 2008 to get surgery. My mother was still alive at this point and seemed supportive. I was morbidly obese at this time with a few co-morbidities, such as high blood pressure and high cholesterol.
Researching My Insurance Benefits
After doing a ton of research to know surgery was for me, I made a call to my health insurance to see if weight loss surgery was a covered benefit. Not all health insurances actually cover weight loss surgery, even if you are sick. To my surprise, my insurance did, indeed, cover weight loss surgery, and not just one or two procedures, but all four. I wrote down their requirements but also looked up my specific medical policy online, just to be sure, for legal purposes. With health insurance coverage, it is sad to say, that sometimes it comes down to the legal part of it. I was under the impression that if it is a covered benefit, and I meet the requirements, I should be allowed treatment. But, as I would soon come to find out, that is not always the case.
I was told I needed to get a referral from my primary care physician (PCP) after following a 6-Month Doctor-Supervised Diet. So, I set out to find a PCP who could refer me, as my usual PCP no longer accepted my insurance. This was the first of many roadbumps.
The Process of Getting a Referral
It took a few months to find a PCP who would accept my insurance. When I did, I made an appointment and was excited to get the ball rolling. But by this time, I had another co-morbidity or two to add to the list: joint pain and back problems that led to decreased mobility.
In September of 2009, I saw a PCP and discussed how I wanted weight loss surgery and would need a referral. Unfortunately, this PCP didn't agree. She said no and that I could lose weight on my own. She did not even ask what I had tried in the past but just saw me as the stereotype that bigger people seem to get in this society. I was devastated. I knew I would need a physician-supervised diet so I stayed with this PCP and had her conduct one. I thought maybe she will change her mind in 6 months when she sees my struggles.
I went back to this doctor every month for weigh-ins and no surprise to me, hadn't lost weight at the end of the 6 month period. I had followed a low carb, low fat, high protein, 1200 calorie diet, at her recommendation, with no success.I again asked her for a referral but she denied my request again and told me to stay on the diet plan with her.
A year went by still with no progress on the doctor-supervised diet. I decided to ask for a referral again. She denied me again. Depressed for getting no results over an entire year, I decided to change doctors, as I saw nothing changing. I needed to find someone who would help me.
I went through several different doctors with no luck. I'd heard everything from doctors about losing weight by this point. I'd go in for a sinus infection and one would say, "you just need to lose weight." I'm no doctor but I'm pretty sure that a sinus infection has nothing to do with weight. Another said, "you just need to try." Really? Not that he cared to ask but when I'd diet, I'd give it 110%. And when I exercise, I tended to do so much I'd overdo it and end up with an injury. Believe me, I was trying! Another said, "you just need to stop eating." Really? Tell me, what part of not eating is healthy? At that point I was eating two meals a day. Another said I needed to be like the trapped miners that were on the news because when they were without food or water, they lost weight. Again, what is healthy about that? Doctors want me to starve myself? In 2010, after routine bloodwork with one of these doctors, I found out I was a type 2 diabetic.
In 2011, I finally had some luck. I saw a PA at a medical clinic and she agreed to refer me. It seemed so easy. I had come with a stack of medical records and research on weight loss surgery and prepared a speech but it wasn't needed -- she just agreed with me. Finally it seemed like I was getting somewhere! She told me to make monthly visits for the doctor-supervised diet but I informed her that I had already completed one and had proof. I made monthly appointments anyways for follow-up. During this time, my pain had gotten severely worse -- to the point of not being able to care for myself on my own. I was in so much pain I couldn't sleep or stand in the shower, cook for myself, nor dress myself. They submitted a pain management , wheelchair, and endocrinologist referrals but they were all denied by my insurance as not medically necessary.
I returned the next month to find nothing had been submitted for the referral yet. I requested with the receptionist that they do so and she said she would.
Another month passed by. Still, there was no referral submitted. Again, I requested that they submitted and again she said she would. This went on for several more months. Finally I was told that it was submitted and I had to wait 2 weeks. After 2 weeks had passed, I called my medical group and asked about the referral. They told me they never received anything from my doctor's office. I was very frustrated and upset but put a call out to my doctor's office and asked that they resubmit the referral.
I kept calling the office and checking up on the referral but nothing had been submitted yet. My health was deteriorating. I didn't know what else to do. It had been years since I was trying to get this surgery. Would it ever happen? I decided to write my doctor's office a letter, outlining my concerns, co-morbidities, and insurance requirements and hand it to them at my next appointment. By this time, my BMI was 46.8 and my co-morbidities included:
- Type 2 Diabetes
- Osteoarthritis of the knees and hip
- Severe low back and sciatic pain
- High cholesterol
- Heartburn
- Sleep apnea
- Asthma
- Inability to do basic daily activities without help
- High triglycerides
The next month I was approved to see a bariatric surgeon. This seemed like good news at the time but was, in fact, another dead end. The doctor I was approved to see did not actually perform the DS. I went to see the surgeon the month to ask him anyways and was even more disappointed. He deemed me too high risk for any surgery that he performs. Apparently the group he is a part of only performs surgery on healthy, low risk patients.
Even though this was another dead end, I didn't give up. I researched online all of the reputable, vetted DS surgeons in my state (courtesy of DSfacts.com), California, and called them to see if they would accept my insurance. I found one doctor in Los Angeles, which was an 8 hour drive from where I live, who would accept my insurance. One doctor in the entire state! Again, I would need a new referral to see him. So, I made an appointment at my doctor's office. Apparently the PA left the practice so I saw a doctor there. As it turns out, it was one of the PCPs I had seen before I came to this place, specifically the one who told me all I needed to do was stop eating. What were the odds that he would come here, too? Oh boy, I was nervous. He agreed to the referral.
I called the medical group to see if they had received the referral but the one they had received was to go back to the surgeon who deemed me too high risk. So I called my doctor's office and had them try again. But the medical group again said it was to go back to the previous surgeon.
The next month I had a doctor appointment and asked the staff to again send the referral in but they did not.
The month after that, now January 2012, I attended a seminar in Los Angeles with the DS surgeon, which was one of their requirements for making the consultation. Then, I had another appointment with my PCP that month and asked they resend the referral. I was informed for the first time that the medical group would keep sending me back to that doctor because he was the only one in-network and that they didn't think I could get any out of town doctor.
On January 17th, I called the medical group and asked what I needed to do to be sent to a surgeon who performed the DS. The customer service reprsentative I spoke with gave me instructions for the doctor's office. It was something as simple as writing something in the part that said 'note.' I called my doctor's office to inform them of this. They wanted me to fax the directions over as they didn't have time to write the information down at that moment and so I did. I called the next day to confirm that they had received the fax and they had. Then, I called almost every day for 4 weeks to see if they had done the referral and they hadn't.
On my February doctor appointment, I asked the office staff in person to please send it again and pointed out that it had been four weeks. She said she would. Two days later, I received a phone call from the staff telling me they faxed the referral. Two days after that I called the medical group to see if they had received it. They told me they hadn't received anything from my doctor's office since December. Five days after that, I called back my doctor's office and again asked that they send in the referral. Later that day, I received a call back from my doctor's office telling me it was sent. This process went on until the end of the month. On February 21st, I filed a grievance against my doctor's office with my health plan for several referrals and prior authorizations they refused to submit.
On February 28th, I received a phone call from my doctor's office informing me that the medical group had denied my referral to the DS surgeon and that I would get a formal denial letter in the mail, which I did, on March 3rd.
As for the grievance, I got a letter back in 30 days from the insurance basically just saying sorry you feel this way. They didn't look into it at all.
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Denied! What to Do Now?Appeal!
I reached out on several message boards for help. I had no idea how to submit an appeal or even write one. I refused to give up. It couldn't be the end just because they denied me. And how could they deny me if it was a covered benefit? I had to look into it more.
I found out there are two different kinds of appeals: internal and external. The internal one is where you appeal with the insurance, which was my next step. The external appeal is where you appeal outside of your insurance. In my case, because my insurance is an HMO and I live in California, the place I would appeal would be the Department of Managed Health Care (DMHC). If I had a PPO, I would appeal at the California Board of Insurance. First, I needed to appeal with my insurance. I felt positive. Even if I got denied again, I still had options.
Appealing wasn't just about writing a letter for your case, you need documentation as well. I included specific studies about the DS in my appeal letter and gathered my records from PCPs all the way back to when I first started the journey of requesting a referral and submitted my appeal to my insurance. Since I had already filed a complaint with my insurance on the other matter, the grievance, I could appeal that with the DMHC and did so later that month.
The next month, April, I received a letter from my insurance. It was another denial. They stated that I did not meet the definition of medical necessity. In the appeal letter I had submitted, I had gone over all of the reasons of how it was medically necessary (BMI, co-morbidities, etc.)
External Appeals
Since I had exhausted all of my internal appeals, my next step was to request an Independent Medical Review (IMR) with the Department of Managed Health Care (DMHC), and I did so about a week later.
I called the DMHC to follow-up a few weeks later. I was told I qualified for about 5 IMRs for all of the referrals that never happened but they were waiting for records from my insurance to see if I qualified for an IMR. And since I was requesting an out of network surgeon, they may send me to someone in network if I qualify. I informed them that there was no one in network. They said they were still working on it and to call back next week for another update if I wished.
During this time I saw a new PCP at the same office. He didn't know what bariatric surgery was but thought it was the worst thing I could ever do. I didn't take his advice. I also heard from an RN case manager from my insurance who tried to get me to withdraw my request for an IMR. I didn't take her advice, either.
On May 5, I received a letter from the DMHC stating that I qualified for an IMR for the DS and sleep study. I then received a call on the 9th from the complaint analyst who sent out the letter who told me I had to withdraw the IMR for the DS or it would be automatically denied and that she needed it in writing today. I was also told that I could re-submit at a later date and she wanted me to get a sleep study. As soon as they received the sleep study results, I could continue with the IMR. I was scared. The DMHC was my last hope of getting approved and I didn't want to get denied, so I wrote the letter.
I finally got my sleep study. I did not have sleep apnea. The RN case manager helped me set up the appointment. As for the other referrals, I was told the medical group had left them all pending but that they would contact my PCP and see if I still needed the referrals. The sleep center said it would take 4-6 weeks to get a result. I couldn't move forward on my IMR until they received the results.
The whole thing didn't make sense to me. My BMI alone qualified me for a DS, so why did it all hang on this sleep study? I called the analyst back to ask her. She told me the IMR for the wheelchair, endocrinologist, and pain management study had been closed out and the results were mailed to me but that I still didn't qualify for the DS IMR. I quoted my medical policy and even the ASMBS requirements for bariatric surgery to her but still was told I did not qualify as the reviewer said I didn't. I then asked if all she needed was the sleep study results to resubmit and she said no that I still would not qualify. She even went so far as to say that if I did qualify then my insurance wouldn't have denied me. Clearly, I was getting no where. I needed some help.
I had some friends help me on my case. When I went to submit the form to legally allow them to help me with my case, the complaint analyst said I couldn't as I didn't have any open IMRs because I had closed them out. I told her the only reason I closed it out was because she had told me to. Again, I was getting nowhere.
I requested the records from the DMHC and found out that the old bariatric surgeon, the one who deemed me too high risk, said some things like, "high risk for DVT/PE," that I cannot exercise due to the mobility situation, etc. I spoke with the reviewer about this stating I did not have a clotting disorder and I followed a couple doctor-supervised diets that documented what I ate and that I exercised. She stated that the reviewer wants me to get it under control. She informed me that I can submit a new IMR but I should submit everything from every doctor in my favor.
With the help of friends, the reviewer no longer was on my case; I had a new person to contact there.
The request for a wheelchair was denied. I ended up having to get one out-of-pocket as I could no longer walk. The request for the endocrinologist was approved. I saw her and she knew what the DS was, that it would be good for me, and could write a letter of support. The request for a pain management clinic was approved but I never got to see the doctor, or anyone else at the clinic. They took one look at my records and told me to lose weight. I obtained a letter of support for the DS specifically from my psychiatrist as well. I paid out-of-pocket to see a DS surgeon for a consult on July 25 to get a letter of support as well. I went to a closer doctor, Dr. Rabkin, in San Francisco. He deemed me a good candidate for the DS. My PCP said he would sign a letter of support but when it came down to it, he refused to since he "was not a surgeon." I mailed in my request for an IMR on August 22, 2012. At this time, my BMI was over 50.
The next week I had an appointment with my PCP and received some bad news. I was diagnosed with congestive heart failure. I was really depressed. A few years back I was told by a doctor that I would not make it to my 30th birthday. I was starting to believe it. Here, at 28, I was diagnosed with heart failure.
In October, I received a letter from the DMHC stating that I was approved to receive an IMR and that I should hear something in 30 days. Just a short couple of weeks later, I received a phone call stating that I was approved! I broke down in tears. I couldn't believe it. They gave the insurance 5 business days to officially approve me to see the doctor in Los Angeles. Unfortunately, though, there was more insurance drama to come.
When a week went by and I hadn't heard anything, I kept calling places to get to the bottom of what was going on. I was approved, what could be taking so long? I was ready to go but the insurance wasn't.
A week after, now November, I called the DMHC they mailed a letter to me. It stated that the insurance company claimed the surgery was not medically necessary for my obesity, diabetes, high blood pressure, high cholesterol, low back pain, feet pain, knee pain. The insurance had 5 working days to approve me.
I received a letter in the mail from the insurance that stated I was approved to have the surgery itself until January 27th, 2013 but it didn't say who with and with no authorization number. I was confused because the insurance hadn't sent me to anyone to have a consultation with. Would I have to pay out of pocket yet again?
Two weeks passed and during this time I kept calling, e-mailing my insurance. On that fifth day, the insurance forwarded it to the medical group, where no one knew how to refer me because it was not one of their contracted doctors and not in their network. They kept telling me there was no outside-of-network benefits.By law, they had to refer me because I gone through the DMHC but they didn't know how. I researched it myself and called several people. I also requested to see Dr. Rabkin in San Francisco, if possible not only because he is closer but because he performs it lap where the doctor in Los Angeles only performs it open. The medical group kept telling me the insurance had to cover it and the insurance kept telling me the medical group had to cover it. It seemed as though I was stuck in the middle, going in circles!
I was told I would receive another letter in the mail but this time with Dr. Rabkin's information on it. I was also in contact with Dr. Rabkin's office and was told to forward that letter to them so that they could negotiate a price with the insurance and then schedule a date.
I received a letter in the mail the next day from the insurance. I thought it was this letter but instead it was a denial letter, stating it is not a covered benefit and it could be provided by network doctors. I was confused and depressed again. It felt like I was getting denied all over again. They legally had to approve me but I was getting a denial letter. Something wasn't right.
I got ahold of someone at the insurance company and they said that that letter was a mistake and that they had accidentally printed out the wrong paperwork. Three days later, I received a call from Dr. Rabkin's office stating that the insurance had called them with an authorization number and they were negotiating a price. A few days later, I received an e-mail from the surgeon's office stating there was a problem with an authorization. Almost a month after an approval from DMHC and still no authorization from the insurance. I kept calling and it seemed like they weren't going to approve me.
Then, I received a phone call Thursday evening, November 29, stating I would be having surgery Monday, December 3rd. I also received phone calls from pre-admissions from the hospital the surgery would be in. It seemed like it was a sure thing. I hadn't even done any pre-op testing yet and I was having surgery that Monday. Talk about a freak out! I had nothing ready! The surgeon's office said to come in that next day because they were going to expedite the tests.
I couldn't believe it. I was an emotional mess. I couldn't believe after fighting for five years I would get to finally have surgery.
I never gave up and it finally happened.
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