Appeal Letter...suggestions?

Ok, I have put ALOT of work into this, and I just want some feedback. What do you all think? Do I need to make some changes? If so, what? Any help would be GREAT! **drumroll please** Aetna Life Insurance Company Attn: Medical Resolution Team P.O. Box 14596 Lexington KY, 40512 Re: Scott W******* Indianapolis IN, 46260 SSN: ***-**-**** Dear Medical Resolution Team: I am writing in regard to a denial of benefits for weight loss surgery, reference number 5001-****-0000-0000. I respectfully request that you please reconsider and allow coverage for Gastric Bypass Surgery and related expenses. I was referred for this surgery by my PCP, Ronald L. Gemma, D.O. who is very concerned about my health. I am a R.C.I. (Cendant) employee. SS# is ***-**-**** and employee identification number is 698500-**-2. About Me: I am a 26 year old super morbidly obese male, 6 foot tall, weighing 432 pounds. My ideal body weight is 157-170. That puts me more than 100 pounds over my ideal body weight. My Body mass index is 59, which is super or severe clinical morbid obesity. Medical History: I was born with a severe clubbed right foot. From the day I was born, until I was 6 years old, I was in a plaster cast, that had to be changed weekly. I was treated by Dr. Linseth, at Riley Hospital for Childeren. Growing up, there was a time where I was bound to a wheelchair for 6 months, due to a major reconstructive surgery. I was released from Riley, and started seeing Dr. Anthony Miller in approx 1993. He has done several surgeries, including one that re-routed a tendon, to wrap around my big toe. For that surgery, I was also bound to a wheelchair for 5 months. So, needless to say, growing up, and still to this day, walking, excersizing, and every day life is very painful. To this day, I still have staples, and other hardware that are litterally holding my foot together. Walking is a very painful part of my everyday life. I also suffer from high blood pressure, acid reflux, and chronic abdominal, and weight bearing joint pain, obstructive sleep apenea, treated with C-PAP, and Depression. Family History: My mother, father, and Maternal Grandmother all suffer from hypertension. My father is an insulin dependant diabetic. I fear that without Gastric bypass surgery, that I too, will become insulin dependant, and that would greatly decrease my quality of life. Dieting history: Plese see inclosed diet history. I would "yo-yo" with my weight, and try fad diet after fad diet. I gave those diets everything I had, and they just did not work for me. Also, please see enclosed dietican notes, and Dr. notes from Dr. Ronald Gemma. I was placed on a 2100 calorie diet, and I did lose 4 pounds. The problem is, with the third month of the program, following it exactly, I gained 10. The Facts: I quote from C. Everette Koop's report regarding obesity; "Historically, physician involvement in the treatment of obesity has been limited. The achievement of a succesful outcome has been difficult. Limited studies reveal that people who complete nonsurgical weight loss programs and lose approximately ten percent of their body weight gain one third of it back within one year and almost all of it back within five years." Additionally the National Institute of Health Consensus Statement reports: "Limited success has been achieved by various techniques that include medically supervised dieting and intensive behavior modification. During such a treatment program, comorbidity factors such as hypertension, dyslipidemia, and diabetes mellitus can be treated by conventional medical therapy in the patient with clinically sever obesity. Although weight may be reduced acceptably, a major drawback to the nonsurgical approach is failure to maintain reduced body weight." I need help with a lifestyle change. Obesity surgery is the tool that I need to be successful in this effort. If I were an alcoholic or if I were a drug addict you would approve treatment that would change the behaviors - this is no different! In a recent issue of JAMA, Robert Yaes wrote, "Certainly, at a time when it is fashionable to claim that alcoholism and drug abuse are illnesses whose treatment should be covered by health insurance, it is inconsistent to blame fat people for their own condition. In our culture, obesity is perceived as more of a cosmetic problem than a medical problem." (Yaes RJ. JAMA. 1993; 270: 1423.) I am NOT doing this for cosmetic reasons. I am not doing this for my family, friends, co-workers, random strangers; I am doing this for myself, and myself alone. I would like to be able to walk up and down the stairs at work, without getting winded. I would like to walk up the stairs to my apartment, without having to stop halfway, because my foot is hurting so badly, and I can not go on. This is absoultey no way to live my life. I am positive of that, and I hope that with the information that I have provided to you, that you will agree with me. I will eagerly await your responce, Respectfully, Scott A. W*******

That sounds very good. I hope they reconsider their decision and approve your request. Good Luck!!!!

might list the meds you are on now that you could be off of with weight loss....that c pap would be sure to go.....that thing is so hateful

Hey Scott, I too have Aetna, and it seems they always denie the first request. Your letter sounds very good (lots of reseach).........Atena has a criteria that they follow..they want history of diets and results ( 3yrs I think) you do meet the co-obestity that they require. Have your PCP write an apeal or the surgeon that you have chosen wrtie an appeal letter also. Good Luck and hang in there......... I had my surgery June 12th. It took about 2 months after all the requirements were met. I am praying for you!!!! The waiting SUCKS but it is Worth it!! Karen

Sounds like a great appeal letter Scott!!! Good luck with your appeal and your journey!!! RNY 7/28/04 296/149/140

Hi Scott. Your letter is terrific, and really does a great job illustrating the problems you're having due to obesity. If the reason that Aetna denied your first request is the goofy "physician supervised weight loss" requirement, you might want to have your doctor write a similar letter of EVERYTHING you've tried while under his care. This is the approach that I chose in order to get approved through Anthem, who also has a tough supervision requirement. Include in your doc's letter all depression meds, any weight loss meds, apnea treatment, etc. You can even be vague about the dates, such as (example): "I've been treating Scott since 1990, and since that time he has made multiple attempts to lose weight under my supervision, including ..." and then list everything you've done, even if your doc wasn't directly involved. It's a bit of spin, but in fact you were still under his care all that time, so it's still true! You can even write the letter yourself (from your doc's point of view) because *****ally knows your case better than you? And hopefully your doc will be willing to sign it. That's what I did. Just my two cents. I'm wishing you the very best of luck!