Re:Department of Managed Health Care? CHRIS HULL????

[Guest guest]

hi...I'm sorry I didn't respond , I missed your post. I live in

Ca. The comp. I work for only has onsurance thru B/C and they are NOT

self insured.I am a PPO..The reason for denial is the DS is

experimental and not medically necessary.

> > Hello all. I've been denied 3'Xs for DS surgery now. I move on to

> the

> > Department of Managed Health Care....Anyone have any experience

> with

> > them??? they will accept my request and review it. I am a little

> > fearfull to turn it in to them as I may leave something out, & if

I

> > turn in too much will they even read it? Also, what I believe I

> need

> > to turn in....was already turned in to Blue Cross and heck if they

> > denied it.......I'm curious what have I left out that would

educate

> > the people making the decisions?

> >

> > Does anyone know the best way to proceed with the DMHC?

> >

> > Steve G.

> > sign me worried and antagonized by B/C

[Guest guest]

Steve,

I am curious about the " not medically necessary " : Is your BMI < 40 or

did they try to trip you up with the requirement for a medically

supervised diet? What kind of documentation do you have on diets? I

am sure you are aware by know of my work on the DS being

investigational. I think that is a hurdle we can overcome with the

facts. The issue of medical necessity is specific to an individual,

but the creteria should be reasonanble. The NIH was rather

unspecific in their requirement that indivduals should try dieting

first. Insurance companies have iterpreted this statement in rather

insconsistant and extreame ways. Unfortunately, the burden will be

on you to prove the creteria used are " unreasonable " . Have they

documented the creteria for you?

Hull

> hi...I'm sorry I didn't respond , I missed your post. I live

in

> Ca. The comp. I work for only has onsurance thru B/C and they are

NOT

> self insured.I am a PPO..The reason for denial is the DS is

> experimental and not medically necessary.

>