What is the name of your state (only U.S. law)? CA
Insurance Company is Kaiser Nor Cal HMO
I have a question that will hopefully be interesting enough for you to answer or mull over, and help me understand the enormous mountain of PITA that I've been going through. I am reluctant to mention that this has to do with weight loss surgery (WLS), but to put things into context and to avoid unnecessary vagueries, I'm putting that out there.
My insurance is very short when it mentions WLS, just saying they cover it when deemed medically necessary. I called member services and asked which types are covered, and she said they covered laparoscopic adjustable gastric banding (Crap-Band), roux-en-y gastric bypass (RNY), and the duodenal switch (DS). I asked if there were specific rules or prerequisites for any of these, like a minimum BMI for DS was my specific thinking... and she said no, just medical necessity. However, I've been through the absolute ringer trying to get Kaiser to approve my DS. I have gone through THREE IMRs through the Dept. of Managed Health Care (a record for them) to get them to compel Kaiser to authorize this procedure, which they really don't want to because they don't perform that procedure in-network and will have to contract out to a surgeon in San Francisco at a higher expense. The thing is, is that the DS is the way better surgery overall and for me specifically and the RNY they're offering me is horrific in my opinion and will preclude certain medications etc. etc. They say that the DS is something they "feel" isn't appropriate for me even though I meet all the criteria by national and by Kaiser's own guidelines.
So my actual question is: How can a health plan offer coverage for a particular procedure, have no written/published restrictions about that procedure, have a patient (me) that qualifies for WLS and to whom they are offering another procedure (lending credence to the medical necessity question, and the qualify for WLS hurdle), and then say no way to my request because "there's no policy on which we're denying your request, we just don't feel it's right for you?" Do they HAVE to cover that procedure because it's part of some mandate? Do they discourage the use of that procedure as a business because it's a loss-leader financially, and use that as a justification to deny me the health care that is covered and for which I qualify? I have out-of-network surgeons (especially the SF surgeon that they'd contract out to) saying that this is appropriate and medically necessary for me, and Kaiser is still saying no way.
Insurance Company is Kaiser Nor Cal HMO
I have a question that will hopefully be interesting enough for you to answer or mull over, and help me understand the enormous mountain of PITA that I've been going through. I am reluctant to mention that this has to do with weight loss surgery (WLS), but to put things into context and to avoid unnecessary vagueries, I'm putting that out there.
My insurance is very short when it mentions WLS, just saying they cover it when deemed medically necessary. I called member services and asked which types are covered, and she said they covered laparoscopic adjustable gastric banding (Crap-Band), roux-en-y gastric bypass (RNY), and the duodenal switch (DS). I asked if there were specific rules or prerequisites for any of these, like a minimum BMI for DS was my specific thinking... and she said no, just medical necessity. However, I've been through the absolute ringer trying to get Kaiser to approve my DS. I have gone through THREE IMRs through the Dept. of Managed Health Care (a record for them) to get them to compel Kaiser to authorize this procedure, which they really don't want to because they don't perform that procedure in-network and will have to contract out to a surgeon in San Francisco at a higher expense. The thing is, is that the DS is the way better surgery overall and for me specifically and the RNY they're offering me is horrific in my opinion and will preclude certain medications etc. etc. They say that the DS is something they "feel" isn't appropriate for me even though I meet all the criteria by national and by Kaiser's own guidelines.
So my actual question is: How can a health plan offer coverage for a particular procedure, have no written/published restrictions about that procedure, have a patient (me) that qualifies for WLS and to whom they are offering another procedure (lending credence to the medical necessity question, and the qualify for WLS hurdle), and then say no way to my request because "there's no policy on which we're denying your request, we just don't feel it's right for you?" Do they HAVE to cover that procedure because it's part of some mandate? Do they discourage the use of that procedure as a business because it's a loss-leader financially, and use that as a justification to deny me the health care that is covered and for which I qualify? I have out-of-network surgeons (especially the SF surgeon that they'd contract out to) saying that this is appropriate and medically necessary for me, and Kaiser is still saying no way.
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