appeal letter

[jillrn 0]

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.

[ReneBean 3]

Wow. That's pretty good. Of course, BCBS is NOT my favorite insurance company right now - I think they are REALLY trying to approve NO ONE for this procedure. Why did they deny you? I have a BMI over their stated max of 50 - so I used medical references that mostly address that - but you can find them in the "Just exploring options" sticky thread, if you want to review.

Just based on your co-morbidity, you should be approved. I really don't know what they are thinking at Blue Cross - except that Lap Band must be cutting into the profit margin!

Good Luck!!

[jillrn 0]

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