Fighting for Success

[SFOTraveler 42]

Hi Everyone!

I am so excited to have found this community online. May name is Alexis, I am 27 and am a stay at home mom to 2 young children.

I recently submitted a claim to UHC for the sleeve surgery and it was denied. I am trying to figure out how to appeal so that it gets approved.

The one major issue is that i haven't been at my current BMI of 40 for 5 years. In fact I have only been at it for a year.

I have no major comorbidities either.

Does anyone have any suggestions on how to appeal this and win???

Thanks so much for your help and I look forward to getting to know everyone.

[Tiffykins 673]

Hi and welcome to VST. I'm sorry about the denial, but UHC is pretty particular with their requirements on getting approval. Without any co-morbidities, or the BMI requirements, I'm not sure that you could even appeal their decision. Have you discussed the options with the insurance coordinator, or surgeon? They maybe able to give you more solid appeal options.

[lmmore 0]

you shouldn't have to be at a BMI of 40 for five years. Find out where it states that in the policy. I would approach it that you would be exposed to a lot of risk during the next 4 years. Checking with you surgeon or PCP for ideas is a good way to go. I was initially rejected for some stupid reason, and my PCP called up the bariatrics and told them they should be ashamed of themselves. I was in orientation the next week. It's good to get someone on your side, to help you fight the battle. Don't give up.....fight it.

[deedee 5]

I don't have any advice, but wanted to say welcome and wish you luck on your appeal!

[SParkle 4]

Hi and welcome

I'm not really knowledgeable about the US and the insurance systems, but one thing did occur to me.

Have you any previous records of your weight?

If you were Xlbs lighter 2 yrs ago, then could you not go in with the argument that in 2 yrs time you'll be Xlbs more... and so on.....possibly costing them more money during the next few years when some of the co-morbidities start to set in. - Perhaps also if you have anything vaguely relevent in family history to throw at them as well??

Stay ever hopeful!

good luck

Kathy

[SFOTraveler 42]

Just wanted to thank you all for your kind words and advice.

I wanted to post my appeal letter... I think it came out well. My goal was to appeal to their sensitivty... we'll see if that works : P

Dear Sir or Madam;

I recently received a denial of benefits for the proposed Laparascopy, a longitudinal gastrectomy (i.e. sleeve gastrectomy) based on the fact that I have not been at a BMI of 40 or higher for 5 consecutive years. I am appealing this decision and hope that based on the facts that I present in the following letter, that the decision will be overturned and I can be approved for surgery as soon as possible. I have attached a copy of the denial to this letter for your records.

I understand that the policy states that I must be at the current BMI or higher for a minimum of 5 years, however I firmly believe that in 5 years, not only will I be much heavier, but I will also have a long list of comorbidities to add to my current morbid obesity. In 2005 I weighed 193 lbs. In 2010 I now weigh over 230 lbs. At the rate at which I am gaining weight I will easily weigh 280 lbs by 2015, which far exceeds the title of morbid obesity. It is this hypothesis that has led me to the option of bariatric surgery, which for someone like me, will literally save a life.

I come from a long line of obese individuals. Not one person in my immediate family is not classified as obese, and many of my extended family member s are morbidly obese. I have a cousin who died of morbid obesity in 2005 at a weight of 650 lbs. She was living life in a wheelchair because she had lost mobility and eventually had a heart attack and died at the age of 35.

Diabetes also runs rampant on both sides of my family; my father, sister, uncles, aunt, grandmother, and grandfather all have been diagnosed with type 2 diabetes. I tested borderline for gestational diabetes for both of my pregnancies and one of my biggest fears is being diagnosed with type 2 diabetes.

In addition, hypertension and high cholesterol also permeate my family?s medical history. My mother, father, sister, aunts, uncles, and cousins ALL have hypertension so severe that they are on medication. My grandmother, mother, and father all have high cholesterol, also severe enough for medication. I see myself as next in line.

Currently, I have chronic heartburn which I fear will transition into GERD in no time. And I have begun snoring, which has the potential to turn to sleep apnea as time passes and my weight increases.

You see, I simply do not have 5 years to wait and see how sick I become. I am attempting to be proactive and save my life. If not for myself, for my 2 young children. My daughter is 2 and a half, and my son is 9 months old. My prayer is that I can have this surgery not only to lose weight, but to bestow upon them proper eating habits and nutrition as well as the love of exercise. As it stands right now, my mobility is affected by my weight and it breaks my heart that I can?t be the mom I want to be simply because of how heavy I am. I am essentially dragging around at least 100 extra pounds with me every single day, which makes it difficult to do simple things like walk up the stairs in my home.

I don?t want to write a research paper about the benefits of the sleeve gastrectomy because I do trust that you are an informed medical professional. But I want to explain why I am choosing this surgery over all of the other options out there.

The reason why I am not simply accepting gastric bypass (e.g. Roux-n-Y) or gastric banding (Lap-Band? or Realize?) is because both have very high rates of long term failure. And the reason why I have chosen not to apply for the Biliopancreatic Diversion with Duodenal Switch is because I feel as though the surgery is A) extreme for someone with my BMI and also leads to nutritional deficiencies and high rates of osteoporosis as the malabsorptive properties of the surgery are almost ?too effective? and can lead to malnutrition. I do believe that the vertical sleeve portion of the DS surgery (sleeve gastrectomy) is the best option for me because it is a highly successful restrictive procedure and I can still absorb the essential nutrients that my body requires without extreme amounts of Vitamin supplementation.

Supporting Literature

A systematic review of the literature covering LSG through January 2009[1] was published in June last year. Conclusion: From the current evidence, including 36 studies and 2570 patients, LSG is an effective weight loss procedure that can be performed safely as a first stage or primary procedure. From this large volume of case series data, a matched cohort analysis, and 2 randomized trials, LSG results in excellent weight loss and co-morbidity reduction that exceeds, or is comparable to, that of other accepted bariatric procedures. The postoperative major complication rates and mortality rates have been acceptably low. Long-term data are limited, but the 3- and 5-year follow-up data have demonstrated the durability of the SG procedure.

A handful of additional work has been published since that literature review concluded, with additional long term durability data and adding considerable support to the efficacy of LSG in resolving diabetes.[2],[3],[4],[5],[6],[7],[8]

Two International Consensus Summits for Sleeve Gastrectomy have been held, the first[9] 10/25-27/2007 and the second[10] 3/19-21/2009. At the second conference, during the consensus part, the audience responded that there was enough evidence published to support the use of SG as a primary procedure to treat morbid obesity and indicated that it is on par with adjustable gastric banding and Roux-en-Y gastric bypass, with a yes vote at 77%.

In conclusion, I ask that you please approve the Sleeve Gastrectomy surgery for me based on the medical information that I have provided as well as personal consideration and kindess. I truly need this surgery to save my life, and I pray every day that it can happen. I appreciate your time and sincerely hope that you can assist me in changing my life and my children?s lives.

Kind Regards,

Alexis

[lmmore 0]

Excellent letter. Run with it.

[SParkle 4]

What a fab letter!

It came across to me that you had done all your research, realised your problems, and your possible future issues and stated them in a clear and matter of fact way.

I wish you all the luck for this.. .let us know how you get on.

Kathy

[sillysuz 0]

Ok, well here goes nothing. I was denied the VSG as well. I just sent my appeal letter to Anthem Blue Cross Blue Sheild, I am praying that the decision is overturned. Please pray for me. I really need this surgery. I have struggled with my weight all my life and after my 2nd child at the age of 34 it has been hard to get the weight off. I am now 41 and the heaviest I have ever been and I fear not being around for my children. What gets me though is a co-worker of mine with the same insurance coverage had the VSG approved. I do believe the insurance company may have made a mistake in approving hers, but if one gets approved, shouldnt mine?

[brittu 42]

I'd recommend calling and talking to someone at UHC. I see nothing in their bariatric policy that requires a BMI > 40 for 5 years. The only reference I see to time is a 6 month supervised diet. They just published an updated policy in June so perhaps an employee was misinformed. You can reference their policy in your discussion and ask them to point out where the 5 year requirement is stated. I don't think you have to go to appeal yet, you might want to dig a little more with t hem first.

UCH Policy:

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Bariatric_Surgery.pdf