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Appeal letter

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Appeal Letter

This is my appeal letter that was sent out February 15, 2012 after initial denial for Sleeve Gastrectomy. I was denied because my BMI is not over 50. If this can help you in any way feel free to pull from my references or my letter.         February 14, 2012 Carefirst BlueCross BlueShield C/o Member Services 10455 Mill Run Circle Owings Mills, MD 21117-5559 Case ID: Member Name: Member Number: [000] Re: Grievance with the Plan following ‘Adverse Decision’ for primary service code 43775 – Laparoscopy, Surgical, Gastric Restrictive Procedure; Longitudinal Gastrectomy (IE, Sleeve Gastrectomy)   To whom it may concern:   In accordance with the Internal Grievance Process of Carefirst BlueChoice Inc. (hereafter the “Plan”), I received a written notice of an Adverse Decision regarding the above identified health care services based on a review of the request for benefits. It was determined that the health service requested was not medically necessary, appropriate, or efficient. I am writing this letter to request redetermination of approval based on research provided. I will also show that I meet the Plan standard for treatment of morbid obesity, that it IS medically necessary, appropriate, and efficient; Sleeve Gastrectomy is a covered and appropriate stand-alone procedure to treat obesity, current body of evidence iterates the need for the procedure and other forms of treatment for obesity are not for me.   According to the Center of Disease Control (CDC), research has shown that as weight increases to levels of “overweight” and “obesity”, the risks for the following conditions increase (3):   - Coronary heart disease - Type 2 diabetes - Cancers (endometrial, breast, colon) - Hypertension - Dyslipidemia (for example, high total cholesterol or high levels of triglycerides) - Stroke - Liver and Gallbladder disease - Sleep Apnea and respiratory problems - Osteoarthritis (a degradation of cartilage and its underlying bone within a joint) - Gynecological problems (abnormal menses, infertility)   At a current weight of 248 (247.8 rounded to the nearest whole number), and height of 66 inches, my BMI is 40.0. This puts me at MORBIDLY OBESE and at HIGH-RISK. As written in your medical policy “Patients with morbid obesity generally have at least a body mass index (BMI) of 40 (35 with certain co-morbid conditions).”(1) Sleeve gastrectomy is also listed in your medical policy as a proposed laparoscopic procedure to treat morbid obesity. Your policy deems it APPROPRIATE and EFFICIENT by listing it as a proposed procedure to treat morbid obesity. My medical doctor and surgeon have deemed weight loss surgery as MEDICALLY NECESSARY for treatment of my morbid obesity. The National Institute of Health Consensus Conference on obesity surgery recommends that surgery be considered for individuals who meet the following criteria: - Individuals with a BMI of 40 kg/m(2) or greater - Individuals with a BMI of 35 kg/m(2) or greater who also have serious medical conditions that would improve with weight loss.(6)   As previously stated, at a BMI of 40 I meet these criteria.   Also, you reference a position paper by the American Society for Metabolic and Bariatric Surgery (ASMBS) from June of 2007. Your update reads as:   - “Sleeve Gastrectomy, Update 2008, January: - Sleeve gastrectomy has been proposed both as a stand-alone gastric restrictive procedure, and as a first stage operation for the extremely morbidly obese patients, e.g. those with body mass index (BMI) exceeding 50, or for those with serious comorbid conditions that would increase risk for morbidity and mortality with the initial use of a malabsorptive procedure such as gastric bypass with Roux-en-Y anastamosis or duodenal switch. Bariatric specialists believe that with the initial weight loss and improvement of comorbid conditions following the sleeve gastrectomy, the malabsorptive procedure can be performed at a later time if necessary with greater safety. In June of 2007, the American Society for Metabolic and Bariatric Surgery (ASMBS) published a position statement on sleeve gastrectomy as a bariatric procedure. The paper states that sleeve gastrectomy may be an option for carefully selected patients, particularly those who are at high risk or super-obese, and that the concept of staging bariatric surgery may have value as a risk reduction strategy in high-risk patients. The paper also suggests that surgeons performing sleeve gastrectomy inform their patients regarding the lack of published evidence for sustained weight loss and provide information regarding alternative procedures with published long-term (>5years) data confirming sustained weight loss and comorbity resolution.”(1)   The update as states for this procedure was last done in 2008. As most medical professionals know policy and opinions change as more research is done and more studies published. The ASMBS recently released an updated position statement on Sleeve Gastrectomy (October 28, 2011) which supports the growing body of evidence that sleeve gastrectomy has value as a stand-alone procedure for the effective treatment of morbid obesity, and falls somewhere between the lap-band and the gastric bypass in results. Your update is NON-CURRENT. The ASMBS is the largest organization for bariatric surgeons in the world. It is a non-profit organization in whom you reference substantially in your own medical policy. I have included a copy of their current and updated position statement, along with tables displaying randomized trials evaluating sleeve gastrectomy and long-term follow-up after sleeve gastrectomy. I will also provide excerpts that support my argument that sleeve gastrectomy is an appropriate, effective, and efficient way to treat my morbid obesity.   In the summary and recommendation portion of the position statement it says: “substantial comparative and long-term data are now published in the peer reviewed literature demonstrating durable weight loss, improved medical comorbities, long-term patient satisfaction, and improved quality of life after Sleeve Gastrectomy. The ASMBS therefore recognizes Sleeve Gastrectomy as an acceptable option as a primary bariatric procedure and as a first stage procedure in high risk patients as part of a planned staged approach. Based on the current published literature, Sleeve Gastrectomy has a risk/benefit profile that lies between the laparoscopic adjustable band and the laparoscopic Roux-en-Y gastric bypass.” (9)   The position statement also supports my argument that the number of 50 (BMI) in your guidelines is arbitrary. In the studies referenced, patients had a BMI of >35 with comorbities or 40> without. There were no studies done that were referenced where all patients had a BMI of 50 or greater as a stand-alone procedure (Shown in the tables provided). There were those kind of patients INCLUDED, which shows some success, but not exclusive. In fact, Mercy Health Partners published a study in August 2011 proposing that laparoscopic sleeve gastrectomy is a safe and effective bariatric procedure for the lower BMI (35.0-43.0 kg/m2) population. The study was a nonrandomized retrospective analysis of 204 patients from a single surgeon operated between July 2006 and April 2010. The study was comprised of 155 women and 49 men with a mean age of 45 years (range 19-70 years), a mean preoperative weight of 126.6 kg, and a body mass index (BMI) of 45.7 kg/m(2). Coming to the conclusion that Laparoscopic Sleeve Gastrectomy (LSG) yields excellent outcomes with low complication rates for morbidly obese patients and advocate LSG as a safe and effective stand-alone procedure, especially with the lower BMI population. (5) There is NO evidence showing reason that Sleeve gastrectomy should be restricted as a stand-alone procedure for patients with a BMI of 50 or greater. There is no evidence showing that this procedure would NOT help me, but to the contrary showing that it would. There are no studies analyzing patients with a BMI of 50 or greater exclusively. Patients with a BMI of 40 or greater (35 or greater with comorbities) are analyzed along with these patients showing SUCCESS. This should mean that with my BMI of 40, I would have success with the Sleeve gastrectomy in bringing me to my surgeon’s goal of 60% EWL and with commitment and work, bring me to my personal goal of a normal BMI.   I have tried to lose weight all kinds of ways (Diet pills, medically supervised diets and exercise, South beach diet, Atkins diet, 1000 calorie diet, Low Carb/high fiber diet). I go to the gym and workout whether I lose weight or not. I have even bought fitness games to do in my free time at home to burn calories and stay active. I FAIL to lose weight despite my efforts. I take in too many calories despite my efforts, and have a sedentary job where I work long hours. Surgery is necessary due to my ever growing weight. I recognize that I am severely overweight with a weight of 248 and 66 inches tall. My surgeon have clearly explained to me that this level of obesity has been shown to be unhealthy and that many scientific studies show that persons of this level of obesity are at increased risks of respiratory disease, high blood pressure, heart disease, high cholesterol, stroke, diabetes, arthritis, clotting problems, cancer and death. Most of these risks already run in my family and put me at even further risk. I DO NOT WANT TO DIE. I believe with a Sleeve Gastrectomy providing me restriction, and my current gym schedule and commitment to be more active, I can lose a significant amount of my excess weight and become a normal, active, healthy person.   By your own medical policy guidelines, I easily meet your requirements for surgery as an option to help battle my morbid obesity. The evidence and research provided and referenced shows that Sleeve gastrectomy is recommended as a stand-alone procedure, and can help me with a BMI of 40. Sleeve Gastrectomy should be provided as an option for those of us who are morbidly obese, but cannot have gastric bypass, and are not comfortable with a foreign mass being placed inside their body.   I cannot have gastric bypass because with my diagnosis of osteoarthritis, I will probably have to take some form of N-SAID all my life for pain. With the gastric bypass my new ‘pouch’ would not be able to handle them, and I would be at risk for ulcers. I am a 27 year old single female, who at some point in the future would love to have children (multiple if possible). With the malabsorptive qualities of the bypass, I would have a high risk pregnancy. I do not wish to put me or my future children at risk. Gastric bypass also leaves you with what essentially is called a ‘remnant stomach’, a non-functioning portion of stomach that if ulcers or cancer comes about CANNOT be endoscopied. I am not comfortable with this procedure. I prefer the Sleeve gastrectomy because my system is NOT being rerouted. What I eat, as little as it could be, will be absorbed. Nutrients and minerals my body needs can be absorbed with no problem. Vitamin deficiency after gastric bypass surgery is a known complication, according to the University of Alabama, Department of Gastrointestinal Surgery in Birmingham, Alabama. (4) Compared to laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass has higher nutrient deficiencies in a prospective study done by Department of Surgery, St. Claraspital, Kleinriehenstrasse 30, Basel, Switzerland. (2)   In summary, I meet the policy requirements for bariatric surgery for treatment of my morbid obesity. I meet NIH requirements for bariatric surgery for treatment of my morbid obesity. Surgery has been deemed medically necessary by my medical doctor, and surgeon. The ASMBS position paper Carefirst references in the plan is non-current, and with the research provided and CURRENT position statement recognizes Sleeve Gastrectomy as a stand- alone procedure. There is no evidence that Sleeve Gastrectomy as a stand-alone procedure should be reserved for patients over 50 BMI. There is no evidence showing problems performing sleeve gastrectomy for patients with a BMI of 40 or greater. On the contrary, there is evidence and studies referenced in this letter showing the benefits of performing sleeve gastrectomy as a stand-alone procedure for patients with a BMI of 40 or greater; or 35 or greater with comorbities that would improve with weight loss. Gastric bypass is NOT a viable option for me, with my need to take n-saids for pain.   I hope you take my research and references into consideration. I know that this is not an emotional decision, but I hope that you can understand why I would fight for a procedure I have researched and read about extensively enough to be comfortable with. I do not take surgery lightly, but I believe that this surgery will save both the insurer and I great cost down the road. Bibliography included if further review of references are needed.     Thoughtfully,     Me   Works Cited "Carefirst Medical Policy 7.01.036." Carefirst BlueCross BlueShield. N.p., n.d. Web. 27 Jan. 2012. <notesnet.carefirst.com/ecommerce/medicalpolicy.nsf/vwwebtablex/4dd2d4d2d0b090>. "Fewer nutrient deficiencies after laparoscopic sle... [Obes Surg. 2010] - PubMed - NCBI." National Center for Biotechnology Information. N.p., n.d. Web. 27 Jan. 2012. <http://www.ncbi.nlm.nih.gov/pubmed/20101473>. "Healthy Weight: Effects of Overweight | DNPAO | CDC." Centers for Disease Control and Prevention. N.p., n.d. Web. 14 Feb. 2012. <http://www.cdc.gov/healthyweight/effects/index.html>. "Incidence of vitamin deficiency after laparoscopic R... [Am Surg. 2006] - PubMed - NCBI." National Center for Biotechnology Information. N.p., n.d. Web. 27 Jan. 2012. <http://www.ncbi.nlm.nih.gov/pubmed/17216818>. "Laparoscopic sleeve gastrectomy is a safe and effe... [Obes Surg. 2011] - PubMed - NCBI." National Center for Biotechnology Information. N.p., n.d. Web. 14 Feb. 2012. <http://www.ncbi.nlm.nih.gov/pubmed/21128003>. "Medscape: Medscape Access." Medscape: Medscape Access. N.p., n.d. Web. 14 Feb. 2012. <http://www.medscape.com/viewarticle/734500_print>. "Results of laparoscopic sleeve gastrectomy: a prospe... [surgery. 2009] - PubMed - NCBI." National Center for Biotechnology Information. N.p., n.d. Web. 25 Jan. 2012. <http://www.ncbi.nlm.nih.gov/pubmed/19081482>. "Third International Summit: Curr... [surg Obes Relat Dis. 2011 Nov-Dec] - PubMed - NCBI." National Center for Biotechnology Information. N.p., n.d. Web. 25 Jan. 2012. <http://www.ncbi.nlm.nih.gov/pubmed/21945699>. nonegiven. "Updated Position Statement on Sleeve Gastrectomy as a Bariatric Procedure." ASMBS 3 (2011): 17. Print. MLA formatting by BibMe.org.



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