Final Draft of appeal letter.

Here it is. The final draft of my appeal letter. Any last minute changes? Let me know. Thanks so much. Also the second letter is the one I wrote from my doctor, and he has agreed to sign it. Aetna Life Insurance Company Attn. Medical Resolution Team P.O. Box 14596 Lexington KY, 40512 Dear Medical Resolution Team: I am writing in regard to a denial of benefits for weight loss surgery, reference number 5001-8902-0000-0000. 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 303-98-**** and employee identification number is 698500-31-2. ABOUT ME:   I am a 26 year old male, 6 feet tall, currently weighing 432 pounds with a Body Mass Index (BMI) of 59 kg/m2, which is super or severe clinical morbid obesity. With my "ideal" body weight being 157-170, I am more than 100 pounds over weight. MEDICAL HISTORY: I was born with a severe clubbed right foot. From birth, until I was 6 years old, my foot was immobilized in a plaster cast that was changed weekly. I was treated by Dr. Linseth, at Riley Hospital for Children. Growing up, there was a time when I was restricted to a wheelchair for 6 months, due to major reconstructive surgery. I was released from Riley, and started seeing Dr. Anthony Miller in approx. 1993; Dr. Miller performed several surgeries, including one that re-routed a tendon, to wrap around my big toe. While recovering from that surgery, I was again restricted to a wheelchair for 5 additional months. So, as you can imagine, growing up and still to this day, walking, exercising, and the activities associated with every day life is painful and a constant source of discomfort and frustration. A sedentary lifestyle is NOT something that I have either desired or chosen. To this day, I still have staples, and other hardware holding my foot together. In addition to the physical problems noted above, I suffer from depression, high blood pressure, acid reflux, chronic abdominal pain, weight bearing joint pain and obstructive sleep apnea that is treated with C-PAP. I currently take Wellbutrin, Protonix, Carafate, and Regalan. And, I take zanax for anexiety. FAMILY HISTORY: My Mother, Father, and Maternal Grandmother all suffer from hypertension. My Father, who is also obese, is an insulin dependant diabetic. Being significantly overweight, and with my father being diabetic, my Doctor and I are concerned that I too will develop adult onset diabetes if my weight is not quickly controlled. DIETING HISTORY: When reviewing the attached diet history, you will see that I have enthusiastically tried numerous diet programs without success. My Dietician has placed me on a 2100 calorie diet (please see attached notes from Dr. Gemma and my Dietician), and while being both compliant and hopeful, I lost only 4 pounds. And, after following it exactly as prescribed (please see the attached food journal), I gained 10 pounds in the third month of the program! This is very frustrating to me as conventional weight loss methods have yet again failed to work for me; had it worked, I would have already achieved weight loss success and would not be composing this letter. In addition to the 2100 calorie diet, and as suggested by my Doctor and Dietician, I engage in aerobic water exercises 3 times a week. THE FACTS - RATIONALLE FOR BARIATRIC SURGERY: Former Surgeon General, C. Everette Koop, reports that "...people who complete nonsurgical weight loss programs and that 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 that only "...limited success has been achieved by various techniques that include medically supervised dieting and intensive behavior modification" and that while weight may be reduced acceptably, "...a major drawback to the nonsurgical approach is failure to maintain reduced body weight." And finally, in a recent issue of JAMA, Robert Yaes wrote that , "In our culture, obesity is perceived as more of a cosmetic problem than a medical problem." (Yaes RJ. JAMA. 1993; 270: 1423.) Please know that I am NOT pursuing approval for Gastric Bypass surgery for cosmetic reasons. I am not doing this for my family, friends or co-workers; I am doing this for myself, as I desire to live a healthier, happier life while enjoying a more active, productive and satisfying lifestyle. I would like to see my nephew, niece, and eventually my own children grow up, graduate from high school, college, and have their own children someday. I know that with the path I am on now, it will not be possible for me realize and experience those things that we all dream of. I have demonstrated through compliance with various diet and exercise programs that I am able to make the lifestyle choices and behavioral modification required. Conventional methods and therapies of weight loss have failed me numerous times. I need help. Gastric Bypass surgery is the only tool available to me that is certain to result in the desired weight loss. In addition, it has been established that most people after having gastric bypass surgery, are no longer dependent on, and are in fact taken off of many, if not all, of the medications, c-pap and other therapies after having the surgery and beginning the weight loss process in earnest. And, since maintaining my current weight could result in the need for additional foot surgery, I am certain that healthcare cost in the future will be greatly reduced and this future savings will definitely offset the cost of Gastric Bypass surgery. SUMMARY: The National Institute of Health has established the following standards and guidelines for medical appropriateness. The NIH says a candidate should: 1. be at least 100 pounds over ideal body weight 2. have a Body Mass Index (BMI) over 40 3. and have no significant contraindications to surgery Being more than 200 lbs. overweight with a BMI of 59.0, I definitely meet all published and accepted criteria for those that should qualify for surgical intervention! As I submit this appeal, I have met the 3 month multidisciplinary pre-surgical regimen outlined in Aetna's Clinical Policy Bulletin 0157 for Obesity Surgery. I am certain that with the information I am providing, you will agree that Gastric Bypass surgery is medically necessary and is the right approach to achieving my weight loss goals. I am asking you to please reconsider your previous decision regarding coverage and approve the gastric bypass procedure that has been deemed medically necessary by my Physician. I would like to thank you in advance for taking the time to read and carefully consider my appeal. Please contact me if you need any further information when reviewing my case. Dr. Gemma letter---- Guion Family Practice 3731 Guion Rd, Suite D, Indianapolis, IN 46222 (317)925-6553 (317)931-9385 FAX To Whom it may concern: As a Physician, Scott A. Williams has been my patient since January of 2004. During that time, I have witnessed his efforts to lose weight and have also witnessed his frustration as he failed to achieve the weight loss desired. Mr. Williams is an intelligent individual who understands the principles of exercise and good nutrition; I am certain he is committed to both. Mr. Williams was unfortunatly born with a severe clubbed right foot, and that prevents him from engaging in many physical and social activities. His blood pressure is extremely elevated and he has a history of symptoms consistent with acid reflux that are now being treated successfully. Mr. Williams also suffers from chronic abdominal pain, severe depression, and anexity and sleep apnea. Acid reflux, excess weight gain and the inability to effectively lose weight occurred soon after a laparascopic cholysystectomy in 2004, indicating that a significant cause of his obesity is medically related and cannot be attributed to behavioral factors alone; this is why numerous conventional therapies have failed to result in the weight loss desired. Mr.Williams is a 26 year old male currently weighing 432 lbs. with a body mass index of 58.6. He has been more than 100 lbs. overweight for over 5 years. With his medical history, along with a significant family history of obesity, cancer, and diabetes, Scott needs to lose at least 80% of his excess weight as quickly as possible to mitigate this serious risk to his life and health. This individuals quality of life, health, longevity and ability to continue as a productive member of society hinges on his ability to lose and maintain a healthy weight. It is certain that the roux-n-y gastric bypass is the only proven procedure that is known to be an effective tool to empower super morbidly obese individuals to lose excess weight and keep it off. This patient has met Aetna's 3 month multidisciplinary pre-surgical regimen. I am asking that you reconsider your previous decision regarding coverage and authorize the gastric bypass procedure for this patient. I have included copies of notes from the Dietician and myself. Sincerely, Ronald L. Gemma, D.O.

I think both look GREAT! I really, really hope these letters do the trick. Best of luck!

Scott, Both letters look great, to the point, and sincere. If I was on the receiving end of these letters, you would be approved in a minute. But I must say I am a bit bias. Good Luck Dan

Scott, Looks great! Here's a few suggestions... *Include the physician supervised plan in your pcp's letter; especially encompassing: what all the diet entailed (2100 cal, exercise, etc), length of time on the pcp plan, frequency of pcp visits for the plan, and what all was discussed/done durring those visits. *Ask your bariatric surgeon & your dietician to write a letter for you to include in your appeal packet. Good luck!! You know I'm pulling for ya! Sherri

Looks great Scott!! I have my fingers crossed for you!! Sam