I just found out I was turned down by Kaiser. They said I do not qualify.

My BMI is 37.5 and I have HP which I have been on 2 meds aday for years. I also have high cholesterol and triglycerides, I guess my numbers are just not high enough. I am really disapointed.Has anyone fought Kasier on this and won?

Edited August 2, 201016 yr by humpty dumpty

That is TERRIBLE NEWS:thumbdown:!!!! I didn't qualify based on my BMI either through my primary doctor. It was only after my orthopedic surgeon put the referral in that my primary doctor signed off on it and the process began.

What a bummer! Do you have to have one or two co-morbidities if your BMI is 35-39? I don't remember. I thought that hypertension counted, but I haven't seen anything about high cholesterol. I could see that one as being iffy since obesity doesn't always mean high cholesterol and vice versa. Have you ever been tested for sleep apnea? I know that seems to be another of the big co-morbidities for consideration. You might not think you have some sleep/breathing issues, but you just don't know. If you had asked me a few weeks ago if I did, I would have said no way!! But, my husband has told me that I snore a lot. He never told me that before! It was usually if I was really tired or sick. Snoring doesn't mean you have sleep apnea, but it also doesn't mean you don't. If I wasn't considering this surgery, I would go ahead and have myself tested just to be sure. However, my BMI is over 40, so I qualify already, and I don't really have any comorbidities. Good BP, decent cholesterol, no major weight-related health conditions - a fairly healthy morbidly obese person.

While I don't know how to go about appealing, I do think you might want to talk with your PCP about being tested for sleep apnea. Are there any other weight related issues that you have? Do you see a specialist for any other conditions that weight loss would help improve?

Don't give up hope!

What about joint pain? Disc disease in your back? Anything like that? Does your state have an insurance commission you could contact and find out what your rights are? Good luck.

I have one knee that has has been bugging me, I did tell my Dr on my last visit. Maybe I can start complaining more about that. My blood sugar has been around 100 the last few times maybe I should eat a few jelly Beans

before they take blood next time lol.

I even thought about putting some weights in my pockets to raise my BMI... I will just keep at it and see what happens.

I even thought about putting some weights in my pockets to raise my BMI

Now that's creative and a "healthy" way to raise your BMI! :001_smile:

My husband works for the department of insurance for the state of CA. He suggests you write to the department of managed health care. They regulate Kaiser.

Edited August 4, 201016 yr by sleeve 4 me
Adding information

Did they give you an exact reason why they turned you down? If so, maybe you can find grounds to appeal. If you can establish medical necessity, you will probably win.

Sleeve for 4 me:

Is the department of managed health care, a State run agenicy?

Here's the link California Department of Managed Health Care Health Plan Complaints and Appeals

I was turned down by Kaiser too they want you have a BMI of 40 or greater or 35 or greater with either diabetes or sleep apnea joint pain HTN or cholesterol are not considered as qualifying comorbidities in their book. Stinks.

What have you been advised by your PCP?

My understanding is that Kaiser will approve and perform the surgery IF in the opinion of your PCP, surgery is a "Medical Necessity".

The surgery will probably improve some of your other medical situation, which would make the surgery appropriate for your overall long range health.

I suggest that you see if you can get your PCP on the same page as you for a recommendation/referral to the Bariactric clinic.

I filed my appeal today with Kaiser, so I have my fingers crossed!

I just got a call from Kasier that my appeal will be reviewed by the Bariatric team and should hear back with in 15 days.

I just got a call from Kasier that my appeal will be reviewed by the Bariatric team and should hear back with in 15 days.

Best wishes with that!! It?s tough sometimes going through insurance. I did it with my Band and the hoops are unreal. At least you know Kaiser does approve the Sleeve, lots of insurances still do not.

Keep fighting!

I just got a call from Kasier that my appeal will be reviewed by the Bariatric team and should hear back with in 15 days.

:thumbup:Way to GO! Ok 15 days is not too long to wait. That is awesome news! I will say a prayer for you:redface1:. Keep me posted!!!