Approved for the Sleeve on Appeal!

Blue Shield of CA originall denied my request for the sleeve, claiming the procedure is experimental/investigational.  I appealed and won!  I was just notified of my approval and I'll have surgery the first week of December!

Here's the appeal letter I sent Blue Shield:

To Whom It May Concern: 

My name is Jon and I‘m morbidly obese. I have arthritis in my knees and degenerative discs (Degenerative Joint Disease) in my back and neck. I’ve had one surgery on my (left) knee so far and I may need knee replacement if I don’t lose weight. I am required to take prescription non-steroidal anti-inflammatory drugs (NSAIDS) to alleviate the pain and swelling associated with arthritis, and to increase mobility in my joints. NSAIDS allow me to function physically, perform my duties at work and exercise with limitations. If I were not able to take NSAIDS the results would be more weight gain, increased damage to my joints, and increased risk for diabetes, heart disease, heart attack and other diseases. Two (2) of my siblings have diabetes. My sister lost a leg to diabetes last year. Without the use of NSAIDS and significant weight loss my health will continue to deteriorate. It is my hope that significant weight loss with the Sleeve Gastrectomy will reduce the affects associated with arthritis and DJD, reduce my risk for other diseases, reduce my required use of NSAIDS, and give me better overall health. I am confident that, after reviewing the information I have provided, you will agree that the Sleeve Gastrectomy is the only appropriate procedure for me and you will approve my request. 

Over the years I have tried diet and exercise to address my obesity - Jenny Craig, Weigh****chers, Atkins, and Phentermine (under a doctor’s care) to name a few. I’ve held a membership at 24-Hour Fitness for 20 years and I go to the gym an average of 3 days a week. I have also employed the help of personal trainers. Nothing has worked. I have given long serious thought to having weight loss surgery. I am aware that weight loss surgery is not a cure but a tool to assist in weight loss. I understand that it requires a lifelong commitment and that my success or failure will depend on my ability to modify my behavior. I have done a great deal of research about the Sleeve. I have spoken with people who have had the procedure and read information from various publications and websites, including the American Society for Metabolic and Bariatric Surgery. I have discussed the risks and benefits of weight loss surgery with several medical professionals – including my bariatric surgeon, primary care physician, orthopedic surgeon, gastroenterologist, and a leading surgeon in the field of sleeve surgery. Based on my history of failure with other weight loss programs, and my required use of NSAIDS, we all have come to the same conclusion: The sleeve is the most appropriate procedure for me. The Sleeve will allow me to continue (required) use of NSAIDS to treat my arthritis and DJD. The use of NSAIDS following other weight loss surgeries, such as the RNY, is not recommended because of the high risk of ulcers and other gastrointestinal problems.

The sleeve is performed wide-spread world-wide and other insurance companies cover the procedure. United Healthcare, Pacific Care, Medicare and Kaiser Permanente all cover the sleeve. Independent Medical Reviews of similar cases have revealed that the efficacy of the sleeve, as a stand alone surgical treatment for morbid obesity, has been validated by peer review. The sleeve has been determined (and recommended) to be the most appropriate procedure for patients *****quire the use NSAIDS.

 The following statements were taken from Independent Medical Reviews regarding the efficacy of the sleeve and patients requiring the use of NSAIDS (ref. Dept of Managed Health Care): 

“The Health Plan has denied authorization for the procedure on the basis that it is considered experimental and is not as good as or better than laparoscopic gastric band (LGB) or laparoscopic Roux-en-Y gastric bypass (LRYGBP) according to the literature. Laparoscopic sleeve gastrectomy is widely accepted in the literature as both a standalone procedure and as the first phase of a two-stage procedure (followed by duodenal switch). Recent trials and reviews of five and eight year-data clearly show that laparoscopic sleeve gastrectomy is as good as or even better than LRYGBP. In the case of this patient, she has a history of peptic ulcer disease, is on lifelong anti-coagulation therapy, and takes non-steroidal anti-inflammatory drugs (NSAIDS) which significantly increases her risk for bleeding… All told, laparoscopic sleeve gastrectomy is the most appropriate weight loss procedure in this particular setting." 

“Recently published eight-year follow-up studies show weight loss to be maintained with results as good as or even better than Roux-en-Y gastric bypass. Uglioni, et al. showed that after five years, there was a 39% failure rate after laparoscopic gastric band. Another factor to consider is that the patient will require the use of anti-inflammatory medication for her joint pain which could be problematic with a Roux-en-Y gastric bypass operation because of potential peptic ulcer formation." 

“Three physician reviewers found that the laparoscopic sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of obesity. The procedure is approved as a primary treatment for morbid obesity in the well-selected patient by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) based on the medical literature documenting safety, efficacy and the availability of five-year data. The patient is also taking non-steroidal anti-inflammatory drugs (NSAIDs) and steroids which are a relative contraindication for LRYGBP as both will promote ulcer formation. The laparoscopic sleeve gastrectomy does not involve the use of a foreign body or malabsorption of vitamins or medications, making it the best clinical option for this patient."

“The laparoscopic sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of obesity. The procedure is approved as a primary treatment for clinically severe obesity in the well-selected patient by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) based on the available medical literature documenting safety, efficacy and the availability of 5-year data“.

“Two physician reviewers found that laparoscopic sleeve gastrectomy has now been performed worldwide several thousand times with excellent results. Recently published eight-year follow-up studies show weight loss to be maintained with results as good as or even better than laparoscopic Roux-en-Y gastric bypass."  

  “The vertical sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of obesity. The procedure is approved as a primary treatment for severe obesity in the well-selected patient by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) based on the medical literature documenting safety, efficacy and the availability of five-year data."

“Two physician reviewers found that many national bariatric programs and Medicare have recognized and accepted sleeve gastrectomy as a legitimate stand alone bariatric procedure." 

“Three physician reviewers found that the laparoscopic sleeve gastrectomy is a well-established procedure for the treatment of morbid obesity. The safety and efficacy of the sleeve gastrectomy has been sufficiently studied." 

Included are letters from  my bariatric surgeon, orthopedic surgeon, and gastroenterologist. I have spoken extensively with each of these doctors and they all support my decision for weight loss surgery, and they all believe that the sleeve is the best procedure for me.

I hope this is helpful for anyone who's seeking to get the sleeve.  I also posted this letter on my profile.

Congratulations. That is great to hear. December will be here before you know it. Good luck, and keep us posted.

Thanks, Weein!

I see your surgeon was Dr. Otero.  My surgeon is Dr. Chin, also from the John Muir Bariatric Center.  What kind of surgery did you have and how have things been for you post-op?

Congratulations Jon. Aren't you glad you did not give up. Please keep us posted on your progress. If you have any questions feel free to post them. Good Luck.

Congratulations darlin...