Appeals letters

Level II

Supplemental Letter for January 9, 2006

January 3, 2006

Dear Review Panel:

Presented to you for review is my case for a gastric procedure known as a laproscopic banding procedure or "Lap-Band". In a lower review, BCBSFL did not dispute that I meet the criteria for the Lap-Band procedure. There is no dispute that I would benefit from weight loss surgery and there is no dispute that losing weight would be beneficial to my health. At issue is the coverage of this surgery and the exception I am requesting for this exclusion. Ironically, I received a phone call a few weeks ago from BCBSFL's new Diagnostics Program that offers support to wellness. Through this program, I gained beneficial information in the form of a booklet, catalog and DVD on the very weight loss surgery I am requesting.

There is evidence in my medical records that I have tried for years multiple weight loss regimens and used pharmacotherapy for obesity under the supervision of my physician, Dr. Alan Sichelman. For my mental state, it is documented by my therapist, Jane Fenby, that I have a full understanding of what this procedure entails and that it will be a lifetime commitment on my part. There is no indication that I am unstable, misinformed with perceptions of unrealistic expectations; Rather so, that I have pursued this avenue under the direction of my primary care physician and other medical personnel, with cooperation, information and education; That I am laying the course for my surgical event and post surgical life by the compass of these individuals and their combined medical expertise demonstrates I am an individual who very much wishes to be healed.

Unquestionably, I am ill and feel I am fighting for my life. As a result of my severe morbid obesity, I suffer from sleep apnea, diabetes, depression, back problems, joint pain, hypertension, migraines, Pictures will show my condition and the severity of my obesity. It is true that my life is endangered. This procedure will prevent the worsening of my condition, alleviate present harmful medical conditions and perhaps cure them. It is the conclusion of my physican(s) and myself that I am in need of this operation. Please authorize my surgery.

Additional:

As providers of health care coverage, Blue Cross and Blue Shield has historically authorized weight loss surgery. Currently, Blue Cross and Blue Shield of North Carolina cut in half hospital re-admissions "by the twelve surgeons in North Carolina that are designated as centers of excellence for bariatric (obesity) surgery." Additionally, BCBSNC was one of the first insurers in the nation to officially recognize centers of excellence for bariatric surgery. Illinois also follows this model as well as South Dakota, Iowa, Michigan and several other states.

In recent publications in the Tampa Bay area, BCBSFL appears to be using bariatric surgery denials as a financial decision rather than one in the best interest of patient care. I must express my concern that with sufficient evidence from their medical providers and informed decisions with which they move forward, it is very troubling that patient/physician decisions of health necessity are disrupted, ignored and denied, superceded by a focus on cost. It is hoped that Florida will soon follow the successful excellence practice as established by Blue Cross and Blue Shield in other states.

Patricia Reeves