jillrn

I found this on Indiana law website anyone good at interpreting the law?? It seems to me this says they have to approve me. February 4, 2005 <HR align=center width=309 SIZE=1> <HR align=center width=309 SIZE=1> <!-- End of font TimesNewRomanRegular with size 10 --><!-- Font changed to TimesNewRomanRegular with size 19 -->SENATE BILL No. 360 _____ <!-- End of font TimesNewRomanRegular with size 19 --><!-- Font changed to TimesNewRomanRegular with size 12 --> DIGEST OF SB 360 <!-- End of font TimesNewRomanRegular with size 12 --><!-- Font changed to TimesNewRomanRegular with size 9 -->(Updated February 2, 2005 11:21 am - DI 104) <!-- End of font TimesNewRomanRegular with size 9 --><!-- Font changed to TimesNewRomanRegular with size 12 --> <!-- End of font TimesNewRomanRegular with size 12 --><!-- Font changed to TimesNewRomanRegular with size 10 --> <!-- Miller--> Citations Affected: IC 5-10; IC 27-8; IC 27-13; noncode. Synopsis: Coverage of surgery for morbid obesity. Removes language in the morbid obesity definition that refers to weight guidelines in the Metropolitan Life Insurance table. Prohibits: (1) the state employee insurance plan; (2) an insurer that issues an accident and sickness insurance policy; and (3) a health maintenance organization that provides basic health care services; from providing coverage for surgical treatment of morbid obesity for an individual who is less than 19 years of age unless two physicians determine that the surgery is necessary to save the life of the individual. Effective: July 1, 2005. <HR align=center width=309 SIZE=1> <HR align=center width=309 SIZE=1> <!-- End of font TimesNewRomanRegular with size 10 --><!-- Font changed to TimesNewRomanRegular with size 19 --> Miller <HR align=center width=309 SIZE=1> <HR align=center width=309 SIZE=1> <!-- End of font TimesNewRomanRegular with size 19 --><!-- Font changed to TimesNewRomanRegular with size 8 --> January 11, 2005, read first time and referred to Committee on Health and Provider Services. February 3, 2005, amended, reported favorably _ Do Pass. <HR align=center width=309 SIZE=1> <HR align=center width=309 SIZE=1><HR><!-- End of font TimesNewRomanRegular with size 8 --><!-- Font changed to TimesNewRomanRegular with size 10 --> February 4, 2005 <!-- End of font TimesNewRomanRegular with size 10 --><!-- Font changed to TimesNewRomanRegular with size 9 --> First Regular Session 114th General Assembly (2005) <!-- End of font TimesNewRomanRegular with size 9 --><!-- Font changed to TimesNewRomanRegular with size 8 --> PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana Constitution) is being amended, the text of the existing provision will appear in this style type, additions will appear in this style type, and deletions will appear in <STRIKE>this</STRIKE> <STRIKE>style</STRIKE> <STRIKE>type.</STRIKE> Additions: Whenever a new statutory provision is being enacted (or a new constitutional provision adopted), the text of the new provision will appear in this style type. Also, the word NEW will appear in that style type in the introductory clause of each SECTION that adds a new provision to the Indiana Code or the Indiana Constitution. Conflict reconciliation: Text in a statute in this style type or <STRIKE>this</STRIKE> <STRIKE>style</STRIKE> <STRIKE>type</STRIKE> reconciles conflicts between statutes enacted by the 2004 Regular Session of the General Assembly. <!-- End of font TimesNewRomanRegular with size 8 --><!-- Font changed to TimesNewRomanRegular with size 19 -->SENATE BILL No. 360 <HR align=center width=56 SIZE=1> <!-- End of font TimesNewRomanRegular with size 19 --><!-- Font changed to TimesNewRomanRegular with size 10 --> A BILL FOR AN ACT to amend the Indiana Code concerning insurance. Be it enacted by the General Assembly of the State of Indiana: <!-- WP Comment <!-- End of font TimesNewRomanRegular with size 10 --><!-- Font changed to TimesNewRomanRegular with size 10 --><!-- End of font TimesNewRomanRegular with size 10 --><!-- Font changed to TimesNewRomanRegular with size 10 --> SOURCE: IC 5-10-8-7.7; (05)SB0360.1.1. --> SECTION 1. IC 5-10-8-7.7 IS AMENDED TO READ AS FOLLOWS [EFFECTIVE JULY 1, 2005]: Sec. 7.7. (a) As used in this section, "covered individual" means an individual who is: (1) covered under a self-insurance program established under section 7( of this chapter to provide group health coverage; or (2) entitled to services under a contract with a prepaid health care delivery plan that is entered into or renewed under section 7© of this chapter. <STRIKE>(a)</STRIKE> ( As used in this section, "health care plan" means: (1) a self-insurance program established under section 7( of this chapter to provide group health coverage; or (2) a contract entered into under section 7© of this chapter to provide health services through a prepaid health care delivery plan. <STRIKE>(</STRIKE> © As used in this section, "health care provider" means a: (1) physician licensed under IC 25-22.5; or <HR> (2) hospital licensed under IC 16-21; that provides health care services for surgical treatment of morbid obesity. <STRIKE>©</STRIKE> (d) As used in this section, "morbid obesity" means: <STRIKE>(1)</STRIKE> <STRIKE>a</STRIKE> <STRIKE>weight</STRIKE> <STRIKE>of</STRIKE> <STRIKE>at</STRIKE> <STRIKE>least</STRIKE> <STRIKE>two</STRIKE> <STRIKE>(2)</STRIKE> <STRIKE>times</STRIKE> <STRIKE>the</STRIKE> <STRIKE>ideal</STRIKE> <STRIKE>weight</STRIKE> <STRIKE>for</STRIKE> <STRIKE>frame,</STRIKE> <STRIKE>age,</STRIKE> <STRIKE>height,</STRIKE> <STRIKE>and</STRIKE> <STRIKE>gender,</STRIKE> <STRIKE>as</STRIKE> <STRIKE>specified</STRIKE> <STRIKE>in</STRIKE> <STRIKE>the</STRIKE> <STRIKE>1983</STRIKE> <STRIKE>Metropolitan</STRIKE> <STRIKE>Life</STRIKE> <STRIKE>Insurance</STRIKE> <STRIKE>tables;</STRIKE> <STRIKE>(2)</STRIKE> (1) a body mass index of at least thirty-five (35) kilograms per meter squared, with comorbidity or coexisting medical conditions such as hypertension, cardiopulmonary conditions, sleep apnea, or diabetes; or <STRIKE>(3)</STRIKE> (2) a body mass index of at least forty (40) kilograms per meter squared without comorbidity. For purposes of this subsection, body mass index is equal to weight in kilograms divided by height in meters squared. <STRIKE>(d)</STRIKE> (e) Except as provided in subsection (f), the state shall provide coverage for nonexperimental, surgical treatment by a health care provider of morbid obesity: (1) that has persisted for at least five (5) years; and (2) for which nonsurgical treatment that is supervised by a physician has been unsuccessful for at least eighteen (18) consecutive months. (f) The state may not provide coverage for surgical treatment of morbid obesity for a covered individual who is less than nineteen (19) years of age unless two (2) physicians licensed under IC 25-22.5 determine that the surgery is necessary to save the life of the individual. <!-- WP Comment <!-- End of font TimesNewRomanRegular with size 10 --><!-- Font changed to TimesNewRomanRegular with size 10 --><!-- End of font TimesNewRomanRegular with size 10 --><!-- Font changed to TimesNewRomanRegular with size 10 --> SOURCE: IC 27-8-14.1-3; (05)SB0360.1.2. --> SECTION 2. IC 27-8-14.1-3 IS AMENDED TO READ AS FOLLOWS [EFFECTIVE JULY 1, 2005]: Sec. 3. As used in this chapter, "morbid obesity" means: <STRIKE>(1)</STRIKE> <STRIKE>a</STRIKE> <STRIKE>weight</STRIKE> <STRIKE>of</STRIKE> <STRIKE>at</STRIKE> <STRIKE>least</STRIKE> <STRIKE>two</STRIKE> <STRIKE>(2)</STRIKE> <STRIKE>times</STRIKE> <STRIKE>the</STRIKE> <STRIKE>ideal</STRIKE> <STRIKE>weight</STRIKE> <STRIKE>for</STRIKE> <STRIKE>frame,</STRIKE> <STRIKE>age,</STRIKE> <STRIKE>height,</STRIKE> <STRIKE>and</STRIKE> <STRIKE>gender,</STRIKE> <STRIKE>as</STRIKE> <STRIKE>specified</STRIKE> <STRIKE>in</STRIKE> <STRIKE>the</STRIKE> <STRIKE>1983</STRIKE> <STRIKE>Metropolitan</STRIKE> <STRIKE>Life</STRIKE> <STRIKE>Insurance</STRIKE> <STRIKE>tables;</STRIKE> <STRIKE>(2)</STRIKE> (1) a body mass index of at least thirty-five (35) kilograms per meter squared, with comorbidity or coexisting medical conditions such as hypertension, cardiopulmonary conditions, sleep apnea, or diabetes; or <STRIKE>(3)</STRIKE> (2) a body mass index of at least forty (40) kilograms per meter squared without comorbidity. For purposes of this section, body mass index is equal to weight in kilograms divided by height in meters squared. <!-- WP Comment <!-- End of font TimesNewRomanRegular with size 10 --><!-- Font changed to TimesNewRomanRegular with size 10 --><!-- End of font TimesNewRomanRegular with size 10 --><!-- Font changed to TimesNewRomanRegular with size 10 --> SOURCE: IC 27-8-14.1-4; (05)SB0360.1.3. --> SECTION 3. IC 27-8-14.1-4 IS AMENDED TO READ AS FOLLOWS [EFFECTIVE JULY 1, 2005]: Sec. 4. (a) Except as provided in subsection (, an insurer that issues an accident and sickness insurance policy shall offer coverage for nonexperimental, surgical treatment by a health care provider of morbid obesity: (1) that has persisted for at least five (5) years; and (2) for which nonsurgical treatment that is supervised by a physician has been unsuccessful for at least eighteen (18) consecutive months. ( An insurer that issues an accident and sickness insurance policy may not provide coverage for a surgical treatment of morbid obesity for an insured who is less than nineteen (19) years of age unless two (2) physicians licensed under IC 25-22.5 determine that the surgery is necessary to save the life of the individual. <!-- WP Comment <!-- End of font TimesNewRomanRegular with size 10 --><!-- Font changed to TimesNewRomanRegular with size 10 --><!-- End of font TimesNewRomanRegular with size 10 --><!-- Font changed to TimesNewRomanRegular with size 10 --> SOURCE: IC 27-13-7-14.5; (05)SB0360.1.4. --> SECTION 4. IC 27-13-7-14.5 IS AMENDED TO READ AS FOLLOWS [EFFECTIVE JULY 1, 2005]: Sec. 14.5. (a) As used in this section, "health care provider" means a: (1) physician licensed under IC 25-22.5; or (2) hospital licensed under IC 16-21; that provides health care services for surgical treatment of morbid obesity. ( As used in this section, "morbid obesity" means: <STRIKE>(1)</STRIKE> <STRIKE>a</STRIKE> <STRIKE>weight</STRIKE> <STRIKE>of</STRIKE> <STRIKE>at</STRIKE> <STRIKE>least</STRIKE> <STRIKE>two</STRIKE> <STRIKE>(2)</STRIKE> <STRIKE>times</STRIKE> <STRIKE>the</STRIKE> <STRIKE>ideal</STRIKE> <STRIKE>weight</STRIKE> <STRIKE>for</STRIKE> <STRIKE>frame,</STRIKE> <STRIKE>age,</STRIKE> <STRIKE>height,</STRIKE> <STRIKE>and</STRIKE> <STRIKE>gender</STRIKE> <STRIKE>as</STRIKE> <STRIKE>specified</STRIKE> <STRIKE>in</STRIKE> <STRIKE>the</STRIKE> <STRIKE>1983</STRIKE> <STRIKE>Metropolitan</STRIKE> <STRIKE>Life</STRIKE> <STRIKE>Insurance</STRIKE> <STRIKE>tables;</STRIKE> <STRIKE>(2)</STRIKE> (1) a body mass index of at least thirty-five (35) kilograms per meter squared with comorbidity or coexisting medical conditions such as hypertension, cardiopulmonary conditions, sleep apnea, or diabetes; or <STRIKE>(3)</STRIKE> (2) a body mass index of at least forty (40) kilograms per meter squared without comorbidity. For purposes of this subsection, body mass index equals weight in kilograms divided by height in meters squared. © Except as provided in subsection (d), a health maintenance organization that provides coverage for basic health care services under a group contract shall offer coverage for nonexperimental, surgical treatment by a health care provider of morbid obesity: (1) that has persisted for at least five (5) years; and (2) for which nonsurgical treatment that is supervised by a physician has been unsuccessful for at least eighteen (18) consecutive months. (d) A health maintenance organization that provides coverage for basic health care services may not provide coverage for surgical treatment of morbid obesity for an enrollee who is less than nineteen (19) years of age unless two (2) physicians licensed under IC 25-22.5 determine that the surgery is necessary to save the life of the individual. <!-- WP Comment <!-- End of font TimesNewRomanRegular with size 10 --><!-- Font changed to TimesNewRomanRegular with size 10 --><!-- End of font TimesNewRomanRegular with size 10 --><!-- Font changed to TimesNewRomanRegular with size 10 --> SOURCE: ; (05)SB0360.1.5. --> SECTION 5. [EFFECTIVE JULY 1, 2005] (a) IC 5-10-8-7.7(f), as added by this act, applies to a self-insurance program or a contract with a prepaid health care delivery plan that is established, entered into, delivered, amended, or renewed after June 30, 2005. ( IC 27-8-14.1-4(, as added by this act, applies to an accident and sickness insurance policy that is issued, delivered, amended, or renewed after June 30, 2005. © IC 27-13-7-14.5(d), as added by this act, applies to a health maintenance organization contract that is entered into, delivered, amended, or renewed after June 30, 2005.

I was all set to be approved had jumped thru all the hoops and everything. Then the same day my paperwork was submitted my dh employer put a restriction on it. It seems I was 1 day too late to be approved. It was not an exclusion till 11-1-05 the same day they received my paperwork Jill

Johnnyreno What?? please explain no offense intended

I know this is not the right forum for this I posted this under insurance too but for those of you that dont go there. This is the letter I came up with for my insurance co. Please tell me what you think or if I should change anything. I used parts of letters I found on the net and added my own issues to it. Here it is any advice would be helpful. November 25, 2005<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p> Dear Sir or Madam,<o:p></o:p> This letter is to appeal your denial for LapBand Bariatric surgery procedure code 43659. <o:p></o:p> I was referred for this surgery by my Endocrinologist, my Gynecologist and my PCP, whom are very concerned about my health because of severe morbid obesity. I am a 30 year old morbidly obese female who is 4’11” tall with a body mass index of 46. The body mass index is calculated by dividing a person's weight in kilograms by their height in meters squared. When a man's BMI is over 27.8, or woman's exceeds 27.3, that person is considered obese. The degree of obesity associated with a particular BMI ranges from mild obesity at a BMI near 27, moderate obesity at a BMI between 27–30, severe obesity at 30–35, to very severe obesity for patients with a BMI of 40 or greater<SUP>1,2,3</SUP>. Therefore, I may be classified as being very severely obese. The annual number of deaths in America attributable to obesity has been estimated to be 300,000 deaths per year<SUP>4,5</SUP>. With my abnormally high BMI, I am at an estimated 190 percent increased risk of death at my present weight.<o:p></o:p> Bariatric Surgery has been a covered procedure under my healthcare plan, with the conditions outlined in my Benefits Guide on page M-42. I have met the requirements outlined as a persistent condition over five years. I have also had over 18 months of unsuccessful physician supervised non- surgical treatment. Please see records already submitted by my physicians. My surgeon’s office as well as myself have contacted Anthem on several occasions to verify the coverage existed. I have been preparing and researching these options given to me by my physicians for some time. I have done the required seminar provided by the bariatric surgeon. I have also attended my preoperative appointment. My paperwork was then submitted to Anthem for final approval. I called a few weeks after the paperwork was sent to check the status and was informed that it was denied due to an exclusion put on the policy as of November 1, 2005. I was never informed of this policy change until the time of denial of the procedure. <o:p></o:p> I am having significant adverse symptoms from my obesity. I have difficulty standing. I have difficulty performing my daily activities, and in participating with my family in recreational activities. I have pain of my weight-bearing joints. An increase in body weight adds trauma to weight bearing joints and excess body weight is a major predictor of osteoarthritis of the knees. This is a mechanical problem and not a metabolic one. Weight loss will markedly decrease the chance of developing osteoarthritis.<o:p></o:p> I also suffer from shortness of breath. There are several abnormalities in pulmonary function in obese individuals. At one extreme are patients with so-called Pickwickian syndrome, or the obesity-hypoventilation syndrome, which is characterized by somnolence and hypoventilation; it eventually leads to cor pulmonale. In patients who are less obese, there is a fairly uniform decrease in expiratory reserve volume and a tendency to reduction in all lung volumes. A low maximum rate of voluntary ventilation and venous admixture is also present. As an individual becomes more obese, the muscular work required for ventilation increases. In addition, respiratory muscles may not function normally in obese individuals.<o:p></o:p> I also suffer from Gastoesphogeal Reflux disease. GERD is associated with the development of esophageal cancer. Because of my acid reflux and pains and aches in my back and legs I have difficulty sleeping, and therefore, am fatigued and tired during the day. This surgery usually cures acid reflux and sleep disturbances.<o:p></o:p> I am also taking the oral diabetic agent Avandia. I have cardiometabolic syndrome, and severe insulin resistance. This makes it increasingly difficult to lose weight. Complications from diabetes are costly and severely debilitating. Many studies report a remission of diabetes and have been advised to stop taking their medications for diabetes after significant weight loss with the lapBand.6 <o:p></o:p> I also suffer from Polycystic Ovarian Syndrome. This causes a variety of health complications including skin issues, hirsutism, infertility, metabolic problems as well as diabetes. An article in Endocrine Abstracts in 2005 outlines the following regarding PCOS and obesity. <o:p></o:p> “Weight reduction in obese subjects with PCOS not only increases the chance of fertility but also improves the long-term prognosis with regard to development of diabetes.” (Endocrine Abstracts (2005) 10 S34) Economic costs of Obesity: Obesity has been shown to directly increase health care costs. In an article in the March 9, 1998 issue of the Archives of Internal Medicine 17, 118 members of the Kaiser Permenente Medical Care Program were studied to determine the association between body fatness and health care costs. The results showed that patients with BMIs greater than 30 had a 2.4 times greater risk for increased inpatient and outpatient costs than patients with BMIs under 30. Americans spend an additional $33 billion dollars annually on weight-reduction products and services, including diet foods, products, and programs. Most of these expenditures, as is evidenced in this case, are not effective. Rather it can expected that they will continue to gain weight and the costs of co-morbid conditions, including the ones they already have and ones they surely will acquire as time goes on, will far outweigh the costs of the LapBand surgery that we are asking you to please approve for me.<o:p></o:p> As you can see I have exhausted all the traditional ways to lose weight. I have put in the time and effort required to meet the requirements for the surgery, only to find out of a sudden exclusion effective the same day I file the paperwork. The LapBand is an approved and proven means to permanently lose weight. Please approve this surgery for me. Thank you.<o:p></o:p> Sincerely, <o:p></o:p> <o:p></o:p> Reference sources:<o:p></o:p> 1. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Institute of Medicine, National Academy of Sciences. 1995; 50-51.<o:p></o:p> 2. Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell, S.M. Increasing prevalence of overweight among US adults. Journal of the American Medical Association. 1994; 272:205-211.<o:p></o:p> 3. Troiano, R.P., Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell, S.M. Overweight prevalence and trends for children and adolescents: The National Health and Nutrition Examination Surveys, 1963 to 1991. Archives of Pediatrics and Adolescent Medicine, 1995; 149:1085-1091.<o:p></o:p> 4. Daily dietary fat and total food-energy intakes: Third National Health and Nutrition Examination Survey, Phase I, 1988-1991. MMWR Morbidity and Mortality Weekly Report. 1994; 43:116-117, 123-125.<o:p></o:p> 5. Weight control: What works and why. Medical Essay. Mayo Foundation for Medical Education and Research, 1994.<o:p></o:p> 6. Henry Buchwald, MD, PhD; Yoav Avidor, MD; Eugene Braunwald, MD; Michael D. Jensen, MD; Walter Pories, MD; Kyle Fahrbach, PhD; Karen Schoelles, MD JAMA. 2004;292:1724-1737. <o:p></o:p> <o:p></o:p>

This is the letter I came up with for my insurance co. Please tell me what you think or if I should change anything. I used parts of letters I found on the net and added my own issues to it. Here it is any advice would be helpful. November 25, 2005 Dear Sir or Madam, This letter is to appeal your denial for LapBand Bariatric surgery procedure code 43659. I was referred for this surgery by my Endocrinologist, my Gynecologist and my PCP, whom are very concerned about my health because of severe morbid obesity. I am a 30 year old morbidly obese female who is 4’11” tall with a body mass index of 46. The body mass index is calculated by dividing a person's weight in kilograms by their height in meters squared. When a man's BMI is over 27.8, or woman's exceeds 27.3, that person is considered obese. The degree of obesity associated with a particular BMI ranges from mild obesity at a BMI near 27, moderate obesity at a BMI between 27–30, severe obesity at 30–35, to very severe obesity for patients with a BMI of 40 or greater1,2,3. Therefore, I may be classified as being very severely obese. The annual number of deaths in America attributable to obesity has been estimated to be 300,000 deaths per year4,5. With my abnormally high BMI, I am at an estimated 190 percent increased risk of death at my present weight. Bariatric Surgery has been a covered procedure under my healthcare plan, with the conditions outlined in my Benefits Guide on page M-42. I have met the requirements outlined as a persistent condition over five years. I have also had over 18 months of unsuccessful physician supervised non- surgical treatment. Please see records already submitted by my physicians. My surgeon’s office as well as myself have contacted Anthem on several occasions to verify the coverage existed. I have been preparing and researching these options given to me by my physicians for some time. I have done the required seminar provided by the bariatric surgeon. I have also attended my preoperative appointment. My paperwork was then submitted to Anthem for final approval. I called a few weeks after the paperwork was sent to check the status and was informed that it was denied due to an exclusion put on the policy as of November 1, 2005. I was never informed of this policy change until the time of denial of the procedure. I am having significant adverse symptoms from my obesity. I have difficulty standing. I have difficulty performing my daily activities, and in participating with my family in recreational activities. I have pain of my weight-bearing joints. An increase in body weight adds trauma to weight bearing joints and excess body weight is a major predictor of osteoarthritis of the knees. This is a mechanical problem and not a metabolic one. Weight loss will markedly decrease the chance of developing osteoarthritis. I also suffer from shortness of breath. There are several abnormalities in pulmonary function in obese individuals. At one extreme are patients with so-called Pickwickian syndrome, or the obesity-hypoventilation syndrome, which is characterized by somnolence and hypoventilation; it eventually leads to cor pulmonale. In patients who are less obese, there is a fairly uniform decrease in expiratory reserve volume and a tendency to reduction in all lung volumes. A low maximum rate of voluntary ventilation and venous admixture is also present. As an individual becomes more obese, the muscular work required for ventilation increases. In addition, respiratory muscles may not function normally in obese individuals. I also suffer from Gastoesphogeal Reflux disease. GERD is associated with the development of esophageal cancer. Because of my acid reflux and pains and aches in my back and legs I have difficulty sleeping, and therefore, am fatigued and tired during the day. This surgery usually cures acid reflux and sleep disturbances. I am also taking the oral diabetic agent Avandia. I have cardiometabolic syndrome, and severe insulin resistance. This makes it increasingly difficult to lose weight. Complications from diabetes are costly and severely debilitating. Many studies report a remission of diabetes and have been advised to stop taking their medications for diabetes after significant weight loss with the lapBand.6 I also suffer from Polycystic Ovarian Syndrome. This causes a variety of health complications including skin issues, hirsutism, infertility, metabolic problems as well as diabetes. An article in Endocrine Abstracts in 2005 outlines the following regarding PCOS and obesity. “Weight reduction in obese subjects with PCOS not only increases the chance of fertility but also improves the long-term prognosis with regard to development of diabetes.” (Endocrine Abstracts (2005) 10 S34) Economic costs of Obesity: Obesity has been shown to directly increase health care costs. In an article in the March 9, 1998 issue of the Archives of Internal Medicine 17, 118 members of the Kaiser Permenente Medical Care Program were studied to determine the association between body fatness and health care costs. The results showed that patients with BMIs greater than 30 had a 2.4 times greater risk for increased inpatient and outpatient costs than patients with BMIs under 30. Americans spend an additional $33 billion dollars annually on weight-reduction products and services, including diet foods, products, and programs. Most of these expenditures, as is evidenced in this case, are not effective. Rather it can expected that they will continue to gain weight and the costs of co-morbid conditions, including the ones they already have and ones they surely will acquire as time goes on, will far outweigh the costs of the LapBand surgery that we are asking you to please approve for me. As you can see I have exhausted all the traditional ways to lose weight. I have put in the time and effort required to meet the requirements for the surgery, only to find out of a sudden exclusion effective the same day I file the paperwork. The LapBand is an approved and proven means to permanently lose weight. Please approve this surgery for me. Thank you. Sincerely, Reference sources: 1. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Institute of Medicine, National Academy of Sciences. 1995; 50-51. 2. Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell, S.M. Increasing prevalence of overweight among US adults. Journal of the American Medical Association. 1994; 272:205-211. 3. Troiano, R.P., Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell, S.M. Overweight prevalence and trends for children and adolescents: The National Health and Nutrition Examination Surveys, 1963 to 1991. Archives of Pediatrics and Adolescent Medicine, 1995; 149:1085-1091. 4. Daily dietary fat and total food-energy intakes: Third National Health and Nutrition Examination Survey, Phase I, 1988-1991. MMWR Morbidity and Mortality Weekly Report. 1994; 43:116-117, 123-125. 5. Weight control: What works and why. Medical Essay. Mayo Foundation for Medical Education and Research, 1994. 6. Henry Buchwald, MD, PhD; Yoav Avidor, MD; Eugene Braunwald, MD; Michael D. Jensen, MD; Walter Pories, MD; Kyle Fahrbach, PhD; Karen Schoelles, MD JAMA. 2004;292:1724-1737.

I have done my seminair my 18 mo supervised diet and all the other hoops. My insurance I called 5 times to verify coverage and read it in my handbook. I had my pre op with the dr and they told me they were sending stuff in that day and that was the 14th I think. I called my insurance a week later they didnt have I called Dr they said oh we are sending it today. I called a week later again insurance didnt have it. SO I called the Dr they said we sent it today-- I was getting a little frustrated but I thought "just be patient" So I called yesterday to find out if I am approved and they said I am denied that dh work put an exclusion on it as of NOV 1 they day they received my paper work!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! I am going to appeal but I know it wont do any good I dont know who to be mad at the DR office or my dh work! I was so helpful that this was the tool to help me get healthy and be around to raise my kids-- I cant believe I was one day too late!!!!!!!!!! Anyone else have approval even though their was exclusions. I had 4 dr's write in saying I need this surgery. I think I will start a web site for self pays and we will all send 5 people $5. for the surg-- like a pyramid scam! Coarse you would have to have 3000 people do it for 5 people to get the surgery!!! Any ideas-- I tried everything and I cant loose weight! Jill PS I know I saw an appeal letter on some web site it was very good any idea where it is?? Jill

I am sure your right and it is probably b/c of the PCOS. I have it too I have never been able to tolerate BC pills but I am soon to try them again as I have had some issues. Jill

because............... Spydr post about too much researching freaking us out really hit home. So if all you people who are already banded would complete the above sentence it would be really really encouraging!

ok you all can think I am the biggest freak out there but my great grandmother taught me this and I swear it works for me 8 out of 10 times. Say this little saying with a rhythm poem... do not pause "Hiccups, Hiccups have I got To my lover I will send them If my lover, loves me not back to me he'll send them." It's weird but it works for me! LOL

I was told I probably wont have to have one. The dr said no unless my insurance required it. I am not sure why other than he knows me-- I work with the dr at the hospital I work with. I am glad in a way I dont have to have one b/c it is $495. and insurance doesnt cover it. My dh is a therapist for addictions and food can be addiction but they wont let him or any of his co workers sign off on me! I will cross my fingers that I do not have to have one.

I would be honest about it too--or at least not lie. If you are honest and he doesnt want to further the relationship b/c of the band well.. then obviously he is not Mr Right. But if you dont say anything eventually you will have to come clean and then you look like you were the one hiding stuff. Honesty is truely the best policy. But if you really dont want to tell him then I would just not say anything--order soup ( make sure you try something like that at home first) eat and talk, if he asks if you want to share a dessert say no thank you. If he brings something up about it you could say " I love soup-- What is your favorite food? or some other question. Try to keep the focas on him people love to tell you about their lives most people will talk all night about themselves. Real ego booster for men too! Good luck let us know how it goes

My letter of medical necessity and request for the lap band was sent to Anthem today. I am praying that they do not give me any trouble, but I am prepared for a fight! We will see my dr said to call Anthem in 2 weeks if we dont hear anything by them-- keep bugging them! Jill

That is great--- your friend will be so happy. As far as non fiction books. Dr Phils new one Family First is good. Magazines are also good as you can actually read thru them on a short plane ride like you are going on. Have a blast! I am from Indiana there is nothing to do here so just enjoy hanging out with your friend and showing off your skinny self! Jill PS YOUR SIGGY SAYS 298 LBS-- You better get that changed! =)

Did you feel weak and dizzy before or after the pain med? Pain meds can make you feel tired, dizzy and nauseated. But you could try eating some protein to see if it helps. Do you have a fever? Have you ever been allergic to Chinese food? They put some weird stuff in Chinese food and I have had a few pt's come in with seizures after eating Chinese. Weird--but I love Chinese food still!

I hate to say it, but be careful b/c what is going to happen if it "gets out" You maybe more embarrassed that you lied to them then just coming clean. I am not wanting to tell alot of people either, I am maybe able to get away with not telling some people for a while, but I know it will get out so I am not going to lie. I work at the hospital I am having it done at and even if I am a "do not report" it will still get around. They say I could use and alias name, but the nurses you care for me will know it is me-- I know everyone there. I am just not looking forward to living in the fish bowl but I will get over it I guess. I am trying to remember I am doing this for me not them so I dont need their approval.-- Just a thought Good luck and remember you always have lots of support on here. Jill

I have PCOS also and I am looking into getting banded I have been unable to really lose weight but you are doing great Especially with pcos. But I still think the band is a great tool for PCOS b/c of the insulin resistance making it so hard to lose and keep weight off. You need to drop ALOT of weight (so do I-- I am not being rude) and I do believe that the band can be a great tool. I think you will do better than alot of people though b/c you have willpower and you have already made some big lifestyle changes. Keep researching and see if it is for you! Good luck! Jill

Well I couldnt maintain 800 cal for more than a few months. I have tried 1600 cal -- no loss 1500 cal--- no loss 1400,1300,1200,1100,1000 etc. I just dont lose-- I am kinda scared this band may not work either, I really can say with a totally clear conscious that i have sincerely tried with all my heart to lose weight . NO CHEATING! NOT EVEN A LITTLE! I will follow to the letter for 4-5 months at a time thinking shirley it will come I will lose some weight-- then I give up and just eat whatever I want after a few months of starving and no weight loss. But I actually enjoy more healthier foods-- but choc, diet coke and pizza are pretty high on my list too. I do think that part of my problem is that it is very hard to have that low of a cal food by eating mostly protein. So I do reley on no fat carbs which have fewer calories than some proteins b/c most proteins have fat and fat has more calories than carbs or proteins. Hmm well I do think the band is worth a try and hopefully it will help some. I need to lose 100 lbs but wow even if I lost 50 how great would that be for my health, I dont care about being skinny so if I only lose 50 of the 100 I need to lose I think I will be ok with that! Jill

I have PCOS and I am overweight my bmi with both my children was about 40 I had to use fertility drugs, have surg, use injectibles--etc. I did finally conceive on clomid after surg, but my pg were difficult and b/c I was overweight I had gestational diabetes and other problems. It was 2 very difficult pg and my babies could have sufferred from it. I dont regret it and they are healthy-- but if you are under 36 I would get some more weight off-- I know how horrible it is to wait! I know how frustrating infertility is-- but your health and your babies will be so much better off if you lose more weight. You want to enjoy your pg as much as possible and you will feel so much better at a lower weight. Give yourself 6 more months- Start in April or May and have a cute little baby to cuddle with and keep warm next winter! Good luck and you are doing awesome on your weight loss btw-- you are such an inspiration to me as I have PCOS too and I am hoping the lap band will help me! Jill

Well- I already had my gallbladder removed after having my first baby (commonly happens after pg) but anyway I am not worried about losing weight fast I am worried about losing weight. Actually I have had 3 dr's tell me I will have to get below 800 cal/ day to lose weight. But I am hoping if I stay very low carb and with the band- I may be able to lose weight I just think I am going to have to steer very clear of carbs b/c of my insulin resistance. Hopefully the band will make it easier b/c I am hoping to feel full after I eat my protein and some low carb veggies?? I know generally speaking very low cal diets can put your body is starvation mode-- but we are not talking about a normal body make up here due to the endocrine disorder. Jill

Off topic-- Dr Hekier--Texarkana eh?? I have a good friend that lives there she is a nurse too and has had GB. I just love the name Texarkana! Do you know of where I can get copies of more medical journals and studies on Obiesity Surg-- esp LB??? thanks Jill

Do any of you count cal? I have had myself down to 800 / day and not lost weight (unbanded) b/c I am severely insulin resistant. My endocrinologist has told me I need to be around 600 cal or under to lose weight. Am I just kidding myself that the band will help me do this?? I dont feel too well on 800 cal and cant stay on that diet for longer than a few months. I can comfortably stay on 1000 cal but I dont lose weight. Do any of you count calories and stay around 600 cal / day? Is this even possible?? I guess I am going to be a turtle if I do get this LB, which is ok (not that I want to be though) but I would hate to have this surg and lose 10 pounds and that is it.

Well Matt my dr basically said--the study was older and they were having some problems with slippage and that is basically resolved now due to a new approach -- he explained the approach but I am not going to try as it is long. He also said they study was somewhat slanted and actually I believe him b/c I found it on a insurance co web site! LOL (my first problem) and that insurance co does not pay for it. He said he has never had one slip or erode yet--but he does know of some erosions but in these cases he said the people were fine and losin weight and decided to keep the band! Hmmm sounds a little dangerous to me! He said some of the patients included in the study should not have been b/c they lumped a few different procedures together that dont coinside (sp?) anyway basically they arent comparing apples to apples or chocolate to chocolate which ever you prefer! =)

Some people were asking about the negative study I found on lap band and here it is-- My Dr put me to ease though he was able to refute most of it with scientific data. This print is small hope you can read it! Dont know how to make it bigger but I will try! Jill Laparoscopic Adjustable Silicone Gastric Banding (LASGB or LAP-BAND):<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p> Recent advances in laparoscopy have renewed the interest in gastric banding techniques for the control of severe obesity. Laparoscopic adjustable silicone gastric banding (LASGB) using the adjustable LAP- BAND, has become an attractive method because it is minimally invasive and allows modulation of weight loss. The claimed advantage of LASGB is the adjustability of the band, which can be inflated or deflated percutaneously according to weight loss without altering the anatomy of the stomach. This method entails encircling the upper part of the stomach using bands made of synthetic materials, creating a small upper pouch that empties into the lower stomach through a narrow, non-stretchable stoma. The reduced capacity of the pouch and the restriction caused by the band diminish caloric intake, depending on important technical details, thus producing weight loss comparable to vertical gastroplasties, without the possibility of staple-line disruption and lesser incidence of infectious complications. However, distension of the pouch, slippage of the band and entrapment of the foreign material by the stomach have been described and are worrisome.<o:p></o:p> The published results of LASGB have been highly variable, perhaps reflecting surgeons' relative lack of experience with this new bariatric surgical procedure. Several studies have reported high rates of complications associated with gastric banding include those associated with the operative procedure, such as splenic injury, esophageal injury and wound infection, and those occurring later, such as band slippage, reservoir deflation/leak, persistent vomiting, failure to lose weight and acid reflux (see e.g., Gustaavson, et al. 2002; Victorzon and Tolonen, 2001; Holeczy, et al., 2001). In studies reported to the FDA, 89% of patients experienced at least one side effect. These included nausea and vomiting (51%), heartburn (34%), abdominal pain (27%), and band slippage or pouch enlargement (24%). Nine percent of patients needed to have another operation to correct a problem with the device. Twenty-five percent had their entire Lap-Band Systems removed, mostly because of adverse side effects. In about one-third of those patients, insufficient weight loss was also reported as a contributing factor to the decision to have the Lap-Band removed.<o:p></o:p> One of the claimed advantages of the LASGB procedure is its reversibility. Kellum (2003) noted, however, that “[t]he fact that two deaths in the FDA study occurred immediately following bend removal (one each from 'mixed drug intoxication' and multiple pulmonary embolism) suggest that secondary operations always carry significant risks.” <o:p></o:p> In addition, the long-term safety of LASGB is undetermined. Kellum (2003) notes that one of the reasons that surgeons may want to proceed cautiously before adopting LASGB is the concern about the long-term problems related to apposition of a foreign body with the gastrointestinal tract. “Older surgeons will recall the many reports of migration and erosion associated with the Angelchick prosthesis for the treatment of esophageal reflux.” Several recent reports have detailed problems with LASGB slippage and erosion (Holeczy, et al., 2001; Silecchia, et al., 2001). Gustavsson & Westling. (2002) provided one of the few reports on the long-term outcomes with LASGB, and concluded that this procedure “will not stand the test of time.” The investigators reported that, after a median follow-up of 7 years, 58% of the patients who had undergone LASGB had been reoperated on, almost always with excision of the banding system and conversion to Roux-en-Y gastric bypass (RYGBP). The reasons for reoperation were esophagitis, band erosion, pouch dilatation, leakage from the balloon, and esophageal dilatation. A lower incidence of band erosion has been reported with the so-called Swedish adjustable gastric band due to the relatively lower pressure exerted on the stomach (Ceelen, et al., 2003). The Swedish adjustable gastric band has not been approved by the U.S. food and Drug Administration, and is currently under investigation. Although the Swedish adjustable gastric band offers the possibility of significant technical improvements over LASGB, it still represents a purely restrictive operation like the vertical banded gastroplasty, which most U.S. surgeons have abandoned in recent years.<o:p></o:p> Because of the lack of direct comparative studies, the comparative efficacy of LASGB with established methods of obesity surgery is undetermined. In studies of laparoscopic adjustable silicone gastric banding reported to the FDA, the mean excess weight loss was 36.2% at 3 years. This figure contrasts with a 40-60% excess weight loss reported in other series of VBG and 50% for RYGB. (Maclean, et al., 1990; Willbanks, 1987; Melissas, et al., 1998) and 50% for gastric bypass (Griffen, et al., 1987; Pories, et al., 1995). Kellum (2003) notes that multiple reports have demonstrated the superiority of RYGB over VBG. Since LASGB, like VBG, is a purely restrictive operation, “one would expect that laparoscopic Roux-en-Y gastric bypass would yield superior long-term weight loss results when compared to laparoscopic Lap-Band placement.” Kellum (2003) cited the report of Belachew and Monami (1996) that concluded that LASGB had an identical weight loss curve to the open VBG performed by the same surgeons. Kellum (2003) concluded that “t is obvious that only a prospective, randomized series would definitively establish which operation is best in terms of safety and efficacy.” <o:p></o:p> Investigators from the Medical College of Virginia, one of the eight original U.S. centers performing LASGB, published their results. (Demaria, et al., 2001). The investigators “did not find LASGB to be an effective procedure for the surgical treatment of morbid obesity.” At the time of the report, LASGB devices had been removed in 41% patients, either because of inadequate weight loss or intolerable side effects. In 71% of patients with bands in place who underwent long-term evaluation, a significantly increased esophageal diameter developed; of these, 72% had prominent dysphagia, vomiting, or reflux symptoms. Of the patients who still had bands in place, more than one-third were reported to currently desire removal and conversion to RYGB for inadequate weight loss. About a third of the remaining patients have persistent severe obesity at least 2 years after surgery but refuse to undergo further surgery or claim to be satisfied with the results. Overall, only about 10% patients who underwent LASGB achieved a body-mass index of less than 35 and/or at least a 50% reduction in excess weight. The authors predicted that the overall need for band removal and conversion to RYGB in their series will ultimately exceed 50%. The researchers concluded that more study is required to determine the long-term efficacy of LASGB. <o:p></o:p> Reporting on the results of a systematic review of the published medical literature on obesity surgery, Gentileschi, et al. (2002) concluded that “the efficacy of [LASGB] cannot be determined because of poor evidence.” An assessment of the literature on obesity surgery conducted for the National Institute for Clinical Excellence concluded that LASGB is both more costly and less effective than RYGB for severe obesity (Clegg, et al., 2001). An assessment of LASGB by the Australian Safety and Efficacy Register of New Interventional Procedures - Surgical (ASERNIP-S) concluded that the “[l]ong-term efficacy of laparoscopic gastric banding remains unproven and further evaluation by randomised controlled trials is recommended to define its merits relative to the comparator procedures” (Chapman, et al., 2002). The French National Agency for Accreditation and Evaluation in Health (ANAES, 2001) concluded that “n view of the inadequate long-term evaluation of either efficacy or inherent risk of gastroplasty rings (notably risks relating to how the prosthetic material is tolerated, and risk of migration of the ring into the stomach), the working group was concerned about the extensive and unevaluated diffusion of this technique which is currently taking place.” An assessment conducted by the BlueCross BlueShield Association Technology Evaluation Center (2003) stated that there is insufficient evidence to conclude that LASGB either improves net health outcomes or whether it is as beneficial as current established surgery, RYGB. “For laparoscopic gastric banding, the available evidence suggests that weight loss at one year is less than that achieved with gastric bypass. More limited evidence on three-year weight loss suggests that this difference in weight loss may lessen over time. Early adverse event rates are low following laparoscopic gastric banding, and are probably lower than gastric bypass. There is a higher rate of long-term adverse events, and there are a number of potentially serious long-term adverse events such as band slippage or erosion. The incidence of slippage of the device from its intended location, or erosion through the gastric wall increases over time, and can result in visceral organ damage, abdominal pain, and intestinal obstruction. The available data are not sufficient to determine the rates of these longer-term adverse events with confidence.” An assessment conducted by the Australian Medical Services Advisory Committee (2003) concluded that LASGB is as effective as VBG but less effective than RYGB in terms of weight loss. The Canadian Coordinating Office of Health Technology Assessment (CCOHTA, 2003) concluded that “[l]ong-term outcomes data on the effectiveness and safety of the laparoscopic adjustable gastric banding procedure is needed.” In a systematic review of the literature on LASGB, Chapman, et al. (2004) concluded “the long term efficacy of LB remains unproved, and evaluation by randomized controlled trials is recommended to define its merits relative to the comparator procedures.”<o:p></o:p> An assessment of LASGB prepared for the California Technology Assessment Forum (Tice, 2004) concluded that this technology did not meet CTAF criteria. Regarding comparisons of LASGB with other established bariatric surgical procedures, the assessment found:<o:p></o:p> Thus, the mean excess weight loss following open or laparoscopic ASGB appears to be roughly equivalent to vertical banded gastroplasty, but significantly less than Roux-en-Y gastric bypass. None of the comparative trials reported on reductions in co-morbidities. Additionally, in spite of lower peri-operative complications, there seem to be more, and more serious, late complications following ASGB. The lack of well controlled, randomized studies precludes any meaningful assessment of the strengths and weaknesses of LapBand compared with Roux-en-Y gastric bypass. Therefore, it cannot be concluded that LB improves net health outcomes as much as or more than established alternatives of roux-en-Y gastric bypass or vertically banded gastroplasty.<o:p></o:p> An evidence review completed by the Ontario Ministry of Health and Long-Term Care (2005) concluded that, “[r]egarding specific procedures, there is evidence that malabsorptive techniques are better than other banding techniques for weight loss and resolution of comorbid illnesses.”

I had my first appt today, and it went well. Wow you can really tell this is a money maker for the surgeon as everyone is SO INCREDIBLEY NICE! LOL much nicer than usual! Well actually I know this surgeon and he is nice most of the time anyway. He is really going to try and help me get the surgery approved and said I should know in 2 weeks or so. This is going soooo fast! The nurse told me the psych eval was not covered by insurance and it is $495.00!!!!!!!!!!!!!!! Oh my goodness-- I need to get a degree in psych and charge $ 250.00 do a couple evals a couple days a week make some serious money!!! Anyway my surgeon said I didnt have to have one unless my insurance required it, so hopefully I wont have to but if they are going to pay for the rest then I guess I wont complain! I really think a psych eval is a big waste of time anyway-- even if one does have an issue one eval isnt going to take care of it. I really think instead a 12 step program or some kind of continous therapy is better. I got to ask all my questions and I showed him a few of the negative studies I have found and he was able to explain them to me.. I feel pretty good about it --now I just wait to hear from Anthem! Oh yea he said no fill for 8 weeks isnt that a little long??? He said one of his pt's is 6 mo out and no fill yet- I guess she is losing! He also said I would more than likely be a slow loser b/c I am very insulin resistant. He said this is where the ineffective gut of the gastric bypass helps-- but I still do not feel like I want to have GB! Jill

My surgeon said the biggest problem is trapped gas-- not being able to expell the gas normally can cause stomach distention and that can actually push up your organs and put pressure on the heart and cause cardiac arrythmias. Jill