My appeal letter
Dorothy J. Thornbrugh
xxxxxxxxxxxxxxxx
Bartlesville, OK 7400x
(918) xxx-xxxx
Preferred Community Choice
P.O. Box 3270
Tulsa, OK 74101-3270
RE: Dorothy J. Thornbrugh
Group No.: xxxxx
ID No.: xxxxxxxxxxx
March 28, 2008
Dear Sir or Madam:
This letter is to appeal your denial for RNY gastric bypass surgery.
I was referred by my primary care physician (PCP), Dr. xxxxxxxxxxx M.D., to Dr. Steve Katsis M.D. for Roux en Y gastric bypass surgery. My PCP is very concerned about my health due to my morbid obesity. I am a 36 year old morbidly obese female, 5’ 3” tall, weigh 228 lbs, with a body mass index (BMI) of 40.4. I meet U.S. Federal Guidelines for the Treatment of Obesity set down in National Institutes of Health Consensus Conference. Released June 17, 1998, the Federal guidelines on obesity were by the National Heart, Lung, and Blood Institute (NHLBI), in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).
What follows is documentation of why this surgery is considered a medical necessity for me:
I am having significant adverse symptoms from my obesity including standing. I have pain in my heals from plantar fasciitis and Morton’s neuroma in both feet with the right being worse, along with numbness associated with it. Walking even short distances is difficult. I have to stop and sit down frequently. I find it impossible to do any kind of exercise due to pain in my knees, lower back, and feet. I also have difficulty performing any daily activities and in participating with my family in recreational activities.
I also suffer from stress incontinence even though I underwent Burch Bladder Suspension in November 2006. Following bladder suspension surgery, I had a relief of symptoms for eight months before the stress incontinence returned with coughing, sneezing and laughing due to the weight of my abdomen. This condition is strongly associated with being overweight and is usually relieved by weight loss.
I have obstructive sleep apnea hypopnea and disordered breathing syndrome with severe sleep fragmentation and associated oxygen desaturations. Morbid obesity and poor sleep hygiene, due to constant fatigue is exacerbating the sleep ailment. Sleep apnea — the stoppage of breathing during sleep — is common in the clinically severe obese. The health effects of this condition may be severe. Sudden drops in blood oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system. About half of people with sleep apnea develop high blood pressure (hypertension), which raises the risk of heart failure and stroke. If there is underlying heart disease, these repeated multiple episodes of low blood oxygen (hypoxia or hypoxemia) can lead to sudden death from a cardiac event. A study published in the New England Journal of Medicine in November 2005 reported that obstructive sleep apnea greatly increases the risk of stroke, regardless of whether a person has high blood pressure.[1]
It has been recommended by Dr. Liphard O. D’Souza M.D. that in addition to CPAP use, I must lose a drastic amount of weight. In the meantime, I am being treated with CPAP 12 cm of water pressure with a RAMP time of 10 minutes. Despite treatment, I still have difficulty staying asleep, excessive daytime sleepiness which may cause me to fall asleep at work or while driving, irritability, moodiness, and concentration / memory problems. This condition has a high mortality rate, and is a life-threatening problem. People are usually cured of sleep apnea by this surgery and the permanent weight loss it brings.
I also suffer from high blood pressure. Essential hypertension, the progressive elevation of blood pressure, is much more common in obese persons, and leads to development of heart disease and damage to the blood vessels throughout the body, causing susceptibility to strokes, kidney damage, and hardening of the arteries. If hypertension is not under control, many complications can occur as a direct result of continued high blood pressure. Sixty percent of hypertensive people are obese. The weight loss attained by gastric bypass surgery will cure hypertension.
Also, I have hypercholesterolemia (high cholesterol). Excess cholesterol can become trapped in the walls of ones arteries. By building up there, the cholesterol helps to cause hardening of the arteries or atherosclerosis. Atherosclerosis causes most heart attacks by slowing or blocking the flow of blood to the heart. So, the heart gets less oxygen than it needs which weakens the heart muscle, and chest pain (angina) may occur. If a blood clot forms in the narrowed artery, a heart attack (myocardial infarction) or even death can result.
Arthritis is a major co-morbid condition that I have. One of the nearly intolerable problems is the constant pain of the weight bearing joints. An increase in body weight adds trauma to weight bearing joints and excess body weight is a major predictor of osteoarthritis. These joints tend to wear out more quickly in the obese. Eventually, joint replacement surgery may be needed to relieve the severe pain. The permanent weight loss of gastric bypass surgery will markedly decrease problems with arthritis and the ever-increasing expenses to the insurance companies that will surely follow.
Because of my weight, I have low self esteem, I am depressed, and suffer from anxiety attacks. Seriously overweight persons face constant challenges to their emotions: repeated failure with dieting, disapproval from family and friends, sneers and remarks from strangers and often times discrimination at work. I find myself avoiding social interactions and public places, which limit my freedom due to fear of embarrassment. I am currently being treated for depression and anxiety with Zoloft 100 mg daily and Xanax 0.50 mg as needed.
Coronary Artery disease is another problem caused by clinically severe obesity. Severely obese persons are approximately six times as likely to develop heart disease as those who are of a normal weight. Coronary disease is pre-disposed by increased levels of blood fats, and the metabolic effects of obesity. Increased load on the heart leads to early development of congestive heart failure. Severely obese persons are 40 times as likely to suffer sudden death in many cases due to cardiac rhythm disturbances. Although I do not currently have coronary artery disease, I have a strong family history of heart disease and my father passed away at age 58 due to heart disease and it scares me to death to think that I could leave my children without a mother at such a young age.
I become short of breath upon any exertion. I cannot climb even one flight of stairs without stopping and have a very difficult time performing the ordinary day-to-day duties of living such as shopping, cleaning, and getting in and out of my car. I was once physically active bicycling, jogging, gardening, and playing with my kids, but at this time I find that I am unable to perform any recreational activities and feel depressed because I cannot lose weight and maintain the loss. I find that exercise causes me to be out of breath very quickly. Losing weight will cure respiratory problems.
I have made many, many attempts to lose weight including:
- Weigh****chers
- Nutri System
- SlimFast
- Frozen meals
- E-diets
- HerbaLife
- Scarsdale Diet, Sacred Heart Diet
- Phentermine
- South Beach Diet, Jorge Cruise (diet & fitness routine)
- Curves for Women
- Bicycling, Rollerblading, walking
- Numerous over-the-counter diet medications
- exercise videos, and exercise equipment
While undergoing the above diets, I also included exercise in my routine. I can and have lost weight, but shortly thereafter, I gain it all back and more. There is not one study that shows that dieting brings permanent weight loss. The National Institutes of Health in 1991 and 1992 consensus statements rebutted conventional diets for morbid obesity, and pointed to this important fact: Diets alone cannot be successful for the morbidly obese.
Obesity has been shown to directly increase health care costs. In an article in the March 9, 1998 issue of the Archives of Internal Medicine, 17,118 members of the Kaiser Permenente Medical Care Program were studied to determine the association between body fatness and health care costs. The results showed that patients with BMIs greater than 30 had a 2.4 times greater risk for increased inpatient and outpatient costs than patients with BMIs under 30. For patients with BMIs greater than 30, the study also showed increases in health care costs related to diabetes and hypertention.
Americans spend an additional $33 billion dollars annually on weight-reduction products and services, including diet foods, products, and programs. Most of these expenditures, as is evidenced in my case, are not effective. Rather it can be expected that I will continue to gain weight over the ensuing years and add to this present list of obesity associated illnesses.
I am seeking gastric bypass surgery because, as documented above, I am unlikely to lose weight and keep it off long-term without non-surgical measures. I ask that you approve this surgery so that I can become a healthy, productive person once again. Thank you.
Sincerely,
Dorothy J. Thornbrugh
[1] Sleep Apnea. http://www.mayoclinic.com Mayo Foundation for Medical Education and Research, 2006.
