Letter of Appeal to BCBS

Well here it is...my PCP has reviewed it for me and I am waiting to hear back from my surgeons office about whether I can see her tomorrow in her office or in clinic on Monday to go over some more details. She goes out of town on Tuesday...so if they say I can't see her face to face then I will buckle and e-mail it to her...also my PCP said she would e-mail herself and discuss the letter with my surgeon if I'd like. The thing is because my surgeon's office requested my OP records from Ohio State as did I, they just faxed them to the surgeon even though the surgeon decided leave the appeal totally up to me. So I need to sit down with my surgeon and the op records to see if there is anything in them that I may need to add to the letter. But I must say I feel I should be approved just with what I have now. Sarah Margaret Blue Cross Blue Shield of Florida Patient Name: Sarah M. B. Physician: Patricia Byers MD Facility: University of Miami Hosp Group ID: XXXXXXXXXX Employer Group Name: ICUBA Member Number: XXXXXXXXX Reference #: XXXXXXXX To Whom It May Concern: I am writing to appeal the denial of coverage for a revision to my Roux-en-Y gastric bypass. I had a Roux-en-Y gastric bypass in April 2003 at The Ohio State University Medical Center in Columbus, Ohio performed by Dr. Charles Cook. I am a 29-year-old female and currently weigh 298lbs with a BMI of 52.7. My BMI places me in the category of being super morbidly obese. As per my policy through ICUBA, the treatment of morbid obesity, including surgical treatment, is a covered benefit and therefore this medically necessary procedure should be covered. The denial letter dated July 10, 2006 stated the reason for denial as: The patient had a rouy en Y bypass and lost weight successfully but has regained weight. This statement is incorrect for two reasons: 1. My pre-op weight was 462lbs. My ideal weight based on my height of 5'3" is 120lbs. Therefore I originally had 342lbs of excess weight to lose. My current weight is 298lbs. I have lost a total of 164lbs which is 48% of excess lost. Therefore, I do not meet the definition of successful post-op weight loss which is between 55-70%. 2. I have not regained weight. The accompanying documentation from my original surgeon's, Dr. Cook, clinical notes and my current primary care physician's, Dr. Livingstone, clinical notes will show my continual documented post-op weight from April 2003 until present. 298lbs is the least I have ever weighed. Final weight with Dr. Cook May 2004: 334lbs. First weight with Dr. Livingstone September 2004:337lbs Current weight 298lbs. Per BCBS medical policy G-24: Repeat or Revised Bariatric Surgical Procedures (43848, 43886-43888) Conversion of a gastric restrictive procedure without gastric bypass (e.g., vertical banded gastroplasty) to a gastric restrictive procedure with gastric bypass (e.g., for morbid obesity) Revision of a failed gastric restrictive procedure (e.g., restapling of dehisced vertical banded gastroplasty staple line, severe adhesions of the gastric pouch, stenosis of stoma, dilation of stoma) A Roux-en-Y gastric bypass (43644, 43846) may be considered medically necessary for patients who have not had adequate weight loss (defined as loss of more than 50 percent of excess body weight) from vertical banded gastroplasty (43842). Since, maximal weight loss is not typically achieved until 1 to 2 years of vertical banded gastroplasty, a Roux-en-Y gastric bypass is considered not medically necessary and not covered if performed within two years of a vertical banded gastroplasty. In addition, a Roux-en-Y gastric bypass following vertical banded gastroplasty is considered not medically necessary and not covered for patients who have been substantially noncompliant with a prescribed nutrition and exercise program following the vertical banded gastroplasty. More than one vertical banded gastroplasty or Roux-en-Y gastric bypass procedure is considered not medically necessary. Reoperation may be required to either "take-down" or revise the original bariatric procedure. Surgical revision or reversal (i.e., take-down) is covered for members who have complications from the primary procedure demonstrated by diagnostic study (e.g., obstruction, stricture, dilation of the gastric pouch). A reoperation or reversal is considered not medically necessary unless the primary bariatric surgery has resulted in complications, and therefore, it is not covered. The accompanying reports from diagnostic tests conducted demonstrate several complications resulting from and associated with the primary Roux-en-Y gastric bypass surgery. Upper Endoscopy: dilated stoma, hiatal hernia Upper GI: gastroesophageal reflux, dilated gastric pouch measuring 7.6 x 5.2 cm. Abdominal CT: large ventral hernia measuring 10.0 cm The gastroesphageal reflux is directly caused from the hiatal hernia and I suffered from neither prior to my Roux-en-Y gastric bypass. The large ventral hernia developed within three months post-op along the mid-incision line made for the open Roux-en-Y gastric bypass. In addition, Dr. Cook's clinical notes show that I indicated during post-op visits that early satiety was not being experienced. However, since I was compliant with nutrition and exercise and losing at the time Dr. Cook did not explore the issue further. I have also included the clinical notes from all post-op visits with the dietician at Ohio State to show I was compliant with the recommended post-op eating plan. The dilated stoma and dilated gastric pouch have led to my inability to lose the remainder of my excess weight, thus continuing to leave me super morbidly obese and suffering with co-morbidities caused by my excess weight. In the past two years, I have been treated for four new co-morbidities that I did not suffer with prior to the primary Roux-en-Y gastric bypass surgery. My primary medical care is currently coordinated by Dr. Keri Livingstone; however, the seriousness of my new co-morbidities, especially considering my relatively young age, requires me to seek treatment from additional specialists. ? Dr. Yeon Ahn, hematologist, and Dr. John MacDonald, thoracic surgeon, treated me following a hospitalization in September 2004 for deep vein thrombosis (DVT) and cellulitis. Dr. Ahn ordered a full hematological work-up to rule out hypercoagulable factors. All of which came back negative. ? Dr. Alejandro Forteza, neurologist, is currently treating me for two transient ischemic attacks (TIA****urring in November 2004 and January 2005. A January 2005 CT scan showed evidence of a stroke. Dr. Forteza ordered diagnostic tests including shunt studies, transcranial Doppler, and carotid duplex. Dr. Forteza also recently prescribed Topamax for weight loss due to his concern for the effect my weight was having on my overall health. ? Dr. Howard Willens, cardiologist, has treated me since January 2005 for heart palpitations and chest pain. Dr. Willens has performed a dobutamine stress echo, EKG, stress test, and 30-day heart monitoring. Dr. Willens diagnosed me with a patent foramen ovale (PFO) in May 2005 and it was treated with transcatheter closure in January 2006. ? Dr. Livingstone has treated me for osteoarthritis of the knees. I had all diagnostic and hematological work-up for other possible risk factors for DVT and TIA and at this point in time the only risk factor for future stroke and blood clots that exists is that I am super morbidly obese. In addition to the four new co-morbidities I have developed, I continue to suffer with co-morbidities that I had before the original Roux-en-Y gastric bypass including lipedema with overlying lymphedema of the lower extremities and chronic skin ulcers on the hanging pannus. ? Dr. MacDonald has treated me for lipedema and lymphedema. ? Dr. Livingstone has treated me for chronic skin ulcers on the hanging pannus. Therefore, I am asking that BCBS make a good faith review of my appeal for a revision to my Roux-en-Y gastric bypass procedure (codes 43848, 43860) based on the medical necessity of the complications from the original surgery, and in order to treat my co-morbid conditions caused by still being super morbidly obese. If you have questions regarding this appeal please contact Dr. Patricia Byers at xxxxxxxxxx, Dr. Keri Livingstone at xxxxxxxxx, or me at xxxxxxxxx. I look forward to a thorough review and expedient decision regarding my case. Sincerely, Sarah M. B Cc: Robin Long - ICUBA Enclosures

Good luck Sarah. My plastic surgeon has said...never give up and never accept the word no. He helped me get my approval for my plastic surgery.

Sarah, Wow! What you have been through! It is pretty amazing to me what some of us go through for this life saving surgery. My sister is in very poor health and has been denied any kind of weight loss surgery. It is apparently excluded in her insurance policy. What really infuriates me is that she is employed by one of the largest health systems in the city of Jacksonville (one that just today announced in the newspaper that it is about to undergo a 400million dollar expansion) and can't get the care that she needs! You are an impressive lady Sarah! I pray that your denial will be reversed and you will get your revision real soon. You certainly deserve to. Good Luck girl! Kathy

Awesome letter - you go girl!!!!!!!! Don't give up. You'll get it in the end I'm sure! It's just such a shame you have to go thru so much!!!!!!!!! Did you know about the Walk From Obesity coming up Sept 30th? It's at Mercy Hospital in Miami, which happens to be where I had my surgery LOL. Let me know if you would like any details. It would be great to meet you if you go!!! The hospital website has details. www.mercymiami.org Good luck with your appeal - I truly hope you get approved - and FAST!!!! Take care and please keep us posted! Jeanne in Miami

Extreemly nice letter

Sarah, I can't believe all the detail you've included. If they don't approve the revision I'll be shocked. One question... you never stated what you hope to accomplish from the revision other than increased wt. loss. What will the revision change and how will it aid in additional wt. loss? You may have included this info, but I missed it. Good luck - you've certainly covered the bases! Vickie J.