If you have questions about the practices of your managed-care coverage, ask the experts at the state Department of Managed Health Care. They take up issues ranging from difficulties getting an appointment to denial of a doctor's recommendation for treatment.
I am in a situation in which I believe that my health plan is asking me to do something that is detrimental to my health. I want to have bariatric surgery to control my weight, which should help me control my diabetes and high blood pressure. But my health plan told me I needed to lose 20 pounds first. I came close to meeting this goal several times but never quite got there.
Three of the medications that I take have a known side effect of causing weight gain. I've also learned that if I reach the goal of 20 pounds, my health plan will schedule the surgery, but if I gain even one pound back before the surgery, it will be canceled.
I understand that health plans use these weight-loss goals as a measurement of a person's ability to make behavioral changes, but it feels like they are subtly discouraging patients from getting this surgery.
– Christina Berger, Sacramento
The DMHC has received a fairly high number of complaints from people with similar concerns regarding this issue. There is some debate on the subject of whether losing a defined amount of weight, usually 10 percent of a person's total weight, prior to having bariatric surgery is beneficial.
However, a significant percentage of the cases reviewed through the state's independent medical review process have overturned health-plan denials based on these weight-loss requirements.
Although your health plan did not require that you lose 10 percent of your body weight, it did deny your request to have the surgery unless you met your assigned weight-loss goal to demonstrate that you were able to make necessary behavioral changes for a safe and successful post-operative outcome.
Because the health plan denied your request based on medical necessity, your concerns qualified for review.
Consistent with previous results, the reviewer determined that it was not medically necessary for you to achieve your plan-imposed weight-loss goal prior to having this surgery. Consequently, your health plan was required to authorize the surgery.
If any consumer believes his or her health plan is putting unnecessary barriers in the way of accessing appropriate care, they can contact the DMHC at any time for assistance. Our goal is to make sure that you get the right care at the right time.
To ask a question, go to www.sacbee.com/ask or write Second Opinion; Features Department; The Sacramento Bee, P.O. Box 15779, Sacramento, CA 95852.
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