Final Draft of Appeal Letter
Anyone wanting to comment, please feel free to do so... Some parts of it are borrowed/edited... but I wanted one last bit of input before I submit it on Monday 
I am writing to appeal the denial of service response to my doctor's letter of medical necessity for gastric restrictive surgery. I began working at Ochsner in April 2005 as a travel nurse. I enjoyed my time at Ochsner and thus remained at after the contract was complete. On July 25, 2005, I joined as a full time staff RN on the MSU unit under Jenell Gleason. I currently work there as a charge nurse, pain resource nurse, and nurse preceptor for newly hired staff nurses. I have worked consistently through the hurricane and recovery. This is despite becoming homeless and losing all personal belongings when my townhouse was destroyed. Because of the storms, I had to relocate next to my parent's home. I am currently living in a RV outside Baton Rouge, LA. I spend several nights a week in a hotel so that I can continue to work at Ochsner. This has been difficult, but my commitment to Ochsner has remained strong. I echo the sentiment posted in our newsletter "My employer, My choice, My family."
As an employee of Ochsner Clinic Foundation, I purchased the "employee and family" insurance plan through Humana. Recently, Dr. William Richardson processed an inpatient authorization request for a laparoscopic Roux-en Y procedure as treatment for morbid obesity. I was notified by Humana that the coverage was denied. The reason I was given was a "lack of medical necessity" since I do not have hypertension, sleep apnea, or diabetes. At age 34, I do have severe back, knee and hip pain which impede my daily activities including sleep. I also have GERD, osteoarthritis, stress incontinence, gallstones, peripheral edema and severe foot pain. My risk for additional hospitalizations and increased medical care costs due to the onset of diabetes and hypertension are extremely high. All of these problems are known to be relieved by this surgery and the resulting weight loss.
This procedure is a covered benefit for patients with a "BMI greater than or equal to 40 with associated co morbidity" per the Humana coverage issue for Surgical Treatment for Severe Obesity (http://apps.humana.com/tad/tad_new/returnContent.asp?mime=application/pdf&id=4778&issue=132).
In the coverage issue mentioned above, cited examples of the co-morbid diseases include joint disease. I have suffered with severe joint pain for many years. I have chronic hip and back pain and I am unable to sleep, walk, or work without pain medication. I have seen physicians at LSU Health Sciences Orthopedics Clinic for my back pain and been told there was nothing more that could be done medically. The physicians told me that I would need to lose weight to relieve the joint pain. My copies of those records were lost with the destruction of my home. A sleep study evaluation was done because of my pronounced insomnia and continuous exhaustion to rule out sleep apnea. While I do not have sleep apnea, I am frequently unable to sleep from the pain in my hip, back, and knee joints. The sleep study was able to confirm that do I wake an average of 12 times per hour. I also have a 1.7 cm gallstone, which will eventually require the removal of the gall bladder in a similar laparoscopic surgery. This surgery could be performed at the same time as the gastric surgery and reduce the need for additional expenses related to a second surgery.
I am currently 318 lbs at a height of 5ft 6in. This makes my BMI 51 and categorizes me at a Class 3 Obesity which is the highest level of risk (http://www.asbp.org/faq.htm#10 and http://www.asbs.org/html/patients/bmi.html). Because of my obesity, my ability to perform at work is also limited. After a fall in a patient room in 2004, I was found to have arthritic changes in my joints, directly related to weight damage. Since that fall 18 months ago, I have fallen 5 more times and two of those falls occurred while working. Recently I was required to transport a critically ill patient to the ICU and I was unable to keep up the rapid pace. I became short of breath and was left behind the team during the transfer. I am also frequently unable to lift patients due to severe back pain. Occasionally I have even been unable to walk or stand without severe pain. My productivity and safety as a worker could be increased greatly with the implementation of this surgery and the subsequent weight loss.
I have been obese for over 20 years. Obesity is not just a cosmetic problem. It's a health hazard. Someone who is 40 percent overweight is twice as likely to die prematurely as an average-weight person. Obesity has been linked to several serious medical conditions, including diabetes, heart disease, high blood pressure, and stroke. Obese women are more likely than non-obese women to die from cancer of the gallbladder, breast, uterus, cervix and ovaries. I am looking for a long term solution to my morbid obesity; I want a chance for durable weight loss and maintenance. I am so tired and discouraged because I have failed to cure this illness for 20 years. I have never failed at anything so thoroughly.
Morbid Obesity has been proven to place patients at "extremely high risk" for hypertension, coronary artery disease, non-insulin-dependent diabetes mellitus, gallbladder disease, sleep apnea, gout, and certain types of cancer (http://www.asbp.org/faq.htm#13). I am already at increased risk for cancer, related to a family history of cancer on both sides of my family. Although obesity is a chronic disease with adverse health consequences, in our society it carries such a stigma that many people -- including health professionals -- believe that the obese person deserves no sympathy at all, let alone medical treatment for the condition. My disease is frequently lethal and denial of treatment is simply not acceptable in this case because it is obviously based not upon reasonable scientific knowledge. It is based upon discrimination and mistaken opinion. Scientific opinions in on the subject all recommend surgery (http://www.asbp.org/faq.htm#14).
Given the widely recognized morbidity of obesity, many expert groups have reviewed available data to provide guidelines for the treatment of obesity. The results of this analysis have been the same. Surgery is recommended for patients who are morbidly obese (BMI > 40). I have a BMI of 51 and thus clearly fit these guidelines. These are the conclusions of the NIH Consensus panel, the American Association of Endocrinologists, the American Diabetic Association, the former Surgeon General C. Everett Koop's group "Shape Up! America", the Johns Hopkins Hospital, the Mayo Clinic and others. All recommend surgery in obese patients with a body mass of more than 40 without co-morbidities or a body mass index of more than 35 with significant other associated medical illnesses (http://www.obesity.org/subs/fastfacts/morbidobesity.shtml and http://www.asbp.org/faq.htm#14).
I have tried many nutrition programs to lose weight. My first diet was at age 12, when I began attending Weigh****chers with my mother. The outcome of these efforts was that I lost some weight but then regained all of the lost weight and more. I have tried numerous weight loss programs including Weigh****chers, Richard Simmons, Susan Powter, AYDS, Dexatrim, Slim Fast, the Nutri-System, Tony Little, and Atkins. On every diet that I have tried, I have lost 15-45 pounds, but as soon as I stop, I gain it all back and more. I have even done several physician supervised diets such as the Aspen Clinic, which I began again last June. On that program I was able to go from 335lbs to 318lbs in 8 weeks prior to Katrina.
In addition, I have tried multiple exercise programs to lose weight. Unfortunately, there was only minimal success. I have participated in many kinds of programs including walking, gym memberships, home aerobics videos, water aerobics and home exercise machines. I have tried counseling and support groups to lose weight, again with limited success. I have been treated with medications in an attempt to control my obesity. The results of drug treatment were minimally effective. I have tried Adipex, Didrex, HCG shots, and Synthroid for thyroid stimulation. All have been temporarily successful, but ultimately I have gained back all the weight that I had lost, and more.
I found in my research, that the National Institute of Health (NIH) has recognized that only 2% of people who try to lose weight, will lose it and keep it off for a period longer that five years. The NIH has stated that surgery is the only permanent solution to keep weight off and avoid death and the diseases associated with obesity. After looking at my 20+ year diet history, surgery is the only permanent solution that can save my life. I suffer from a severe medical illness that has caused me severe disability and has an excellent chance of being cured by a three-night stay in the hospital.
This denial of treatment is unquestionably based upon the unsupported but widespread opinion that obesity is a failure of character and will power. That opinion is not at all supported by any medical literature or by anyone knowledgeable or expert in the field of the treatment of obesity. What is true is that each and every expert panel that has been brought together to look at this issue from the NIH to Milliman and Robertson have come to the same conclusion. Given my medical condition, surgery is the appropriate treatment. This denial of service is as inappropriate as one that might be based upon my race, gender or religious preference. I do not have a weak character. I am not lazy.
Humana further asserts in the coverage issue mentioned above: "There is reasonably good data reported in nationally recognized peer-reviewed medical literature published in the English language to support the use of surgical treatment following the failure of more conservative weight reduction measures" (http://apps.humana.com/tad/tad_new/returnContent.asp?mime=application/pdf&id=4778&issue=132). This inpatient authorization request should be granted. It is the right choice medically, for a patient with BMI >50. It is also the right choice financially, since the subsequent weight loss will also drastically reduce the risk for other co-morbid conditions that can lead to expensive inpatient stays.
I am writing to appeal the denial of service response to my doctor's letter of medical necessity for gastric restrictive surgery. I began working at Ochsner in April 2005 as a travel nurse. I enjoyed my time at Ochsner and thus remained at after the contract was complete. On July 25, 2005, I joined as a full time staff RN on the MSU unit under Jenell Gleason. I currently work there as a charge nurse, pain resource nurse, and nurse preceptor for newly hired staff nurses. I have worked consistently through the hurricane and recovery. This is despite becoming homeless and losing all personal belongings when my townhouse was destroyed. Because of the storms, I had to relocate next to my parent's home. I am currently living in a RV outside Baton Rouge, LA. I spend several nights a week in a hotel so that I can continue to work at Ochsner. This has been difficult, but my commitment to Ochsner has remained strong. I echo the sentiment posted in our newsletter "My employer, My choice, My family."
As an employee of Ochsner Clinic Foundation, I purchased the "employee and family" insurance plan through Humana. Recently, Dr. William Richardson processed an inpatient authorization request for a laparoscopic Roux-en Y procedure as treatment for morbid obesity. I was notified by Humana that the coverage was denied. The reason I was given was a "lack of medical necessity" since I do not have hypertension, sleep apnea, or diabetes. At age 34, I do have severe back, knee and hip pain which impede my daily activities including sleep. I also have GERD, osteoarthritis, stress incontinence, gallstones, peripheral edema and severe foot pain. My risk for additional hospitalizations and increased medical care costs due to the onset of diabetes and hypertension are extremely high. All of these problems are known to be relieved by this surgery and the resulting weight loss.
This procedure is a covered benefit for patients with a "BMI greater than or equal to 40 with associated co morbidity" per the Humana coverage issue for Surgical Treatment for Severe Obesity (http://apps.humana.com/tad/tad_new/returnContent.asp?mime=application/pdf&id=4778&issue=132).
In the coverage issue mentioned above, cited examples of the co-morbid diseases include joint disease. I have suffered with severe joint pain for many years. I have chronic hip and back pain and I am unable to sleep, walk, or work without pain medication. I have seen physicians at LSU Health Sciences Orthopedics Clinic for my back pain and been told there was nothing more that could be done medically. The physicians told me that I would need to lose weight to relieve the joint pain. My copies of those records were lost with the destruction of my home. A sleep study evaluation was done because of my pronounced insomnia and continuous exhaustion to rule out sleep apnea. While I do not have sleep apnea, I am frequently unable to sleep from the pain in my hip, back, and knee joints. The sleep study was able to confirm that do I wake an average of 12 times per hour. I also have a 1.7 cm gallstone, which will eventually require the removal of the gall bladder in a similar laparoscopic surgery. This surgery could be performed at the same time as the gastric surgery and reduce the need for additional expenses related to a second surgery.
I am currently 318 lbs at a height of 5ft 6in. This makes my BMI 51 and categorizes me at a Class 3 Obesity which is the highest level of risk (http://www.asbp.org/faq.htm#10 and http://www.asbs.org/html/patients/bmi.html). Because of my obesity, my ability to perform at work is also limited. After a fall in a patient room in 2004, I was found to have arthritic changes in my joints, directly related to weight damage. Since that fall 18 months ago, I have fallen 5 more times and two of those falls occurred while working. Recently I was required to transport a critically ill patient to the ICU and I was unable to keep up the rapid pace. I became short of breath and was left behind the team during the transfer. I am also frequently unable to lift patients due to severe back pain. Occasionally I have even been unable to walk or stand without severe pain. My productivity and safety as a worker could be increased greatly with the implementation of this surgery and the subsequent weight loss.
I have been obese for over 20 years. Obesity is not just a cosmetic problem. It's a health hazard. Someone who is 40 percent overweight is twice as likely to die prematurely as an average-weight person. Obesity has been linked to several serious medical conditions, including diabetes, heart disease, high blood pressure, and stroke. Obese women are more likely than non-obese women to die from cancer of the gallbladder, breast, uterus, cervix and ovaries. I am looking for a long term solution to my morbid obesity; I want a chance for durable weight loss and maintenance. I am so tired and discouraged because I have failed to cure this illness for 20 years. I have never failed at anything so thoroughly.
Morbid Obesity has been proven to place patients at "extremely high risk" for hypertension, coronary artery disease, non-insulin-dependent diabetes mellitus, gallbladder disease, sleep apnea, gout, and certain types of cancer (http://www.asbp.org/faq.htm#13). I am already at increased risk for cancer, related to a family history of cancer on both sides of my family. Although obesity is a chronic disease with adverse health consequences, in our society it carries such a stigma that many people -- including health professionals -- believe that the obese person deserves no sympathy at all, let alone medical treatment for the condition. My disease is frequently lethal and denial of treatment is simply not acceptable in this case because it is obviously based not upon reasonable scientific knowledge. It is based upon discrimination and mistaken opinion. Scientific opinions in on the subject all recommend surgery (http://www.asbp.org/faq.htm#14).
Given the widely recognized morbidity of obesity, many expert groups have reviewed available data to provide guidelines for the treatment of obesity. The results of this analysis have been the same. Surgery is recommended for patients who are morbidly obese (BMI > 40). I have a BMI of 51 and thus clearly fit these guidelines. These are the conclusions of the NIH Consensus panel, the American Association of Endocrinologists, the American Diabetic Association, the former Surgeon General C. Everett Koop's group "Shape Up! America", the Johns Hopkins Hospital, the Mayo Clinic and others. All recommend surgery in obese patients with a body mass of more than 40 without co-morbidities or a body mass index of more than 35 with significant other associated medical illnesses (http://www.obesity.org/subs/fastfacts/morbidobesity.shtml and http://www.asbp.org/faq.htm#14).
I have tried many nutrition programs to lose weight. My first diet was at age 12, when I began attending Weigh****chers with my mother. The outcome of these efforts was that I lost some weight but then regained all of the lost weight and more. I have tried numerous weight loss programs including Weigh****chers, Richard Simmons, Susan Powter, AYDS, Dexatrim, Slim Fast, the Nutri-System, Tony Little, and Atkins. On every diet that I have tried, I have lost 15-45 pounds, but as soon as I stop, I gain it all back and more. I have even done several physician supervised diets such as the Aspen Clinic, which I began again last June. On that program I was able to go from 335lbs to 318lbs in 8 weeks prior to Katrina.
In addition, I have tried multiple exercise programs to lose weight. Unfortunately, there was only minimal success. I have participated in many kinds of programs including walking, gym memberships, home aerobics videos, water aerobics and home exercise machines. I have tried counseling and support groups to lose weight, again with limited success. I have been treated with medications in an attempt to control my obesity. The results of drug treatment were minimally effective. I have tried Adipex, Didrex, HCG shots, and Synthroid for thyroid stimulation. All have been temporarily successful, but ultimately I have gained back all the weight that I had lost, and more.
I found in my research, that the National Institute of Health (NIH) has recognized that only 2% of people who try to lose weight, will lose it and keep it off for a period longer that five years. The NIH has stated that surgery is the only permanent solution to keep weight off and avoid death and the diseases associated with obesity. After looking at my 20+ year diet history, surgery is the only permanent solution that can save my life. I suffer from a severe medical illness that has caused me severe disability and has an excellent chance of being cured by a three-night stay in the hospital.
This denial of treatment is unquestionably based upon the unsupported but widespread opinion that obesity is a failure of character and will power. That opinion is not at all supported by any medical literature or by anyone knowledgeable or expert in the field of the treatment of obesity. What is true is that each and every expert panel that has been brought together to look at this issue from the NIH to Milliman and Robertson have come to the same conclusion. Given my medical condition, surgery is the appropriate treatment. This denial of service is as inappropriate as one that might be based upon my race, gender or religious preference. I do not have a weak character. I am not lazy.
Humana further asserts in the coverage issue mentioned above: "There is reasonably good data reported in nationally recognized peer-reviewed medical literature published in the English language to support the use of surgical treatment following the failure of more conservative weight reduction measures" (http://apps.humana.com/tad/tad_new/returnContent.asp?mime=application/pdf&id=4778&issue=132). This inpatient authorization request should be granted. It is the right choice medically, for a patient with BMI >50. It is also the right choice financially, since the subsequent weight loss will also drastically reduce the risk for other co-morbid conditions that can lead to expensive inpatient stays. 
Hi, Kat,
It certainly is thorough and well documented. The teacher in me offers the following editing:
line 3 "...remained at..." might be worded "...chose to continue working after the contract had expired."
in the paragraph about falling at work: "short of breath and was left behind the team during the transfer." might be worded "short of breath; the rest of the team had to continue the transfer without my help."
"denial of treatment is simply not acceptable in this case because it is obviously based not upon reasonable scientific knowledge." might be worded "...obviously not based upon..."
With my best wishes, BS
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