appeal letter

[jillrn 0]

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.

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[gentlespirit 1]

I think it sounds great...you have obviously covered the topic well. Someone who has had to go through the appeals process may have other suggestions...I haven't heard from my ins. co. My only suggestion would be that the sentence just preceding the "6" footnote isn't well constructed...you should add something like "many patients" have been advised to stop taking their diabetes medications...otherwise it sounds like studies have been advised...

That's just my administrative assistant's soul talking! I've always been a stickler for grammar because I think it makes a big difference in the impression we leave...

Good luck with your appeal!

Just my 2 cents.

Emily

[4my3girls 0]

Just words of encouragment. I was denied last year for a breast reduction, even though, well let me just say they were HUGE hung down to my waist all my adult life, even before kids my shoulders back and head hurt. Well the office called me and said sorry your insurance did not approve your surgery call us in the future if your insurance carrier changes, we can try it again I was DEVESTATED, so I called the insurance right away and asked why was I denied, and the rep. said oh no we didn't deny it the office didn't give us all the information needed. SO i called the office back and she said yes we did , but I will resubmit it, and I said before you do that I coming down with a letter that Id like you to fax with it. 2 days later APPROVED!!! Just call the insurance company and make sure that the Dr. office sent all documentaion, the insurance company said when they send the non approval that the receptionist or whoever receives it, will not read the whole page which differs from company to company. It will work out in your favor they have to give you a reason it was denied. Then you can fix the reason-whatever it might be, it may take time but it will work out if you qualify!!!

[jillrn 0]

Johnnyreno What?? please explain no offense intended

[ReneBean 3]

Johnny - the specific doc names are medical citations from the letter. They are publicly available to anyone. No legal ramifications. No one has complained about any particular doctor, nor has anyone attacked anyone.

No problem.

[jillrn 0]

Thank you ReneBean-- I am just here looking for help and support from those who know this all best--the ones that have been here. To describe my letter as "very controversial" is a bit extreme. I know Johnnyreno you have had some problems on here but I was not involved nor do I wish to be. Please can anyone give me some helpful comments?--thank you to those few people that already did. Emily thank you I agree I hadnt caught that I have corrected it on my main draft thanks

Jill