Wisconsin Medicaid Denial & Appeal

My request for a prior authorization was denied for gasrtric bypass surgery. I submitted the following for a request for an appeal. I am appealing your decision for denying my medically necessary weight loss surgery by requesting a hearing, regarding the denial of a prior authorization for # 43644 Lap Gastric Bypass surgery. At 42 years of age, I am 5'5" and weigh 250 pounds, which calculates to be a body mass index of 42, which is considered to be morbidly obese, or 100 - 140 pounds overweight. My neck is 16" and my abdomen measures 51-1/2", indicating that I have excessive fat around my abdomen and my body type is an "apple-shape". As medical professionals, you would be aware that my condition is very serious. I have gone from having baby fat to being chubby to a few extra pounds to obese to morbidly obese. I know that diet and exercise aid in weight loss, but as a long-term resolution to permanent weight loss only 5% of people succeed. I have tried Nutri-Systems, and twice I have joined Weigh****chers. I have also been on medically supervised diets with 3 different physicians. I have purchased diet pills over the internet, tried various diets and joined 3 different health clubs. Sometimes I would lose a little weight, but I always gained it back, plus a few extra pounds. Being morbidly obese I suffer everyday trying to do the simplest tasks such as trying to bend over to tie my shoes. Due to the additional weight and bone spurs, my lower back hurts when I stand even for a short period of time and I have terrible pain in my knees when I have to climb stairs. Even walking at a normal pace leaves me out of breath and my heart racing. I have been diagnosed with Poly Cystic Ovarian Syndrome (PCOS). PCOS is associated with increased risk for insulin resistance, type 2 diabetes, high blood pressure, high cholesterol and heart disease. Weight loss plays a major part in managing PCOS and is the line of attack to minimize current symptoms and attempt to delay or prevent worsening of the underlying conditions of heart disease, insulin resistance, type 2 diabetes and high blood pressure. It is possible that PCOS will worsen with age, especially with weight gain. Many obese women do not overeat. It is a fact that when you are insulin resistant your body converts every calorie it can into fat, even if you are dieting. The result is that while the body is gaining weight, the energy cells are actually starving. Diet medications may temporally work, but the weight will return when the medication is stopped. I, along with an estimated 60 million Americans have insulin resistance. One in four of us will go on to develop type 2 diabetes. Being insulin resistant, excessive amounts of free-floating glucose remain in my blood stream until it is sent to my liver and converted to excess body fat. In addition, hyperinsulinemia encourages my liver to produce even more triglycerides, which lead to a series of biochemical reactions with wide-ranging consequences that can lead to a variety of other serious health conditions, such as coronary heart disease, hypertension, diabetes and some cancers. Obese women who have lost weight have shown to have significantly lower insulin levels. Aging and insulin resistance silently lays the foundation of increasing my risk of having a heart attack. Heart attacks and heart disease run on both sides of my family. Both of my grandfathers died of a heart attack. My great grandfather had diabetes and had to have his legs amputated. Two of my uncles had diabetes and died of a heart attack. Three of my aunts had bypass surgery and two others took heart medication. All of the above family members also had high blood pressure. I suffer from depression and many women with PCOS suffer some physical or psychological manifestations of depression. There is some medical literature suggesting a link between diabetes and depression and perhaps that might be extended to early stages of insulin resistance. Another source of the depression is the effect that PCOS systems may have on self-esteem. In addition to being morbidly obese, I also have severe acne and excessive facial hair. Due to the excess weight, I get yeast infections under my breasts and under my abdomen. I have researched gastric bypass surgery and fully understand the all of the risks involved. As my weight increases and my health deteriorates, the risks of being morbidly obese out way the risks of the surgery. I know that gastric bypass surgery is the only way that my health will improve. I am committed to the requirements of the surgery and look forward to losing all of my excess weight and being able to exercise to get my body in shape and stay fit for the rest of my life. I pray that you will use your education and experience and take all of the facts that I have presented to you and grant me the prior authorization that I need to have the medically necessary surgery to save my life. I was granted an appeal hearing and these are my notes for the hearing. The PA/Physician Attachment listed diagnoses of hypertension, shortness of breath on exertion, snoring, mild reflux, migraines, elevated fasting glucose, depression and sleep difficulty related to restless leg syndrome. A chart note dated August 8, 2006 gives a body mass index as 40.77 with comorbid conditions of diabetes mellitus, hypertension, arthritis and depression. The medication lists contains no medications for diabetes mellitus. Body Mass Index (BMI) From the time when my chart was noted on August 8, 2006, my BMI has increased from 40 to 42. Since my diagnosis of insulin resistance in June 2004, my weight has increased 46 pounds, from 208 pounds to 254 pounds. The weight increase since my chart note of April 12, 2006, is 23 pounds. This is a clear indication that insulin resistance is continuing to deteriorate my health and threaten my life. Weight & Body Mass Index (BMI): April 12, 2006 231 38 Obese (30 - 39.9) May 9, 2006 235 39 Obese (30 - 39.9) May 23, 2006 235 39 Obese (30 - 39.9) June 8, 2006 235.8 40.42 Morbidly Obese (40+) August 8, 2006 N/A 40.77 Morbidly Obese (40+) November 22, 2006 255 42 Morbidly Obese (40+) December 29, 2006 255 42 Morbidly Obese (40+) January 2, 2007 254 42 Morbidly Obese (40+) The chart note states (near) diabetes mellitus. Since being diagnosed with Insulin Resistance in June 2004, I have been taking 2000 MG daily of the prescription medication Metformin. Metformin is a biguanide-type medicine used along with a diet and exercise program to control high blood sugar in patients with type 2 diabetes. This medication works by helping restore the body's proper response to insulin that the body naturally produces and by decreasing the amount of sugar that the liver makes and that the stomach and intestines absorb. Controlling high blood sugar helps prevent heart disease, strokes, kidney disease, and blindness and circulation problems. Arthritis I do have hypertrophic spurring about the lumbar interspaces and the left medial femorotibal joint. Osteoarthritis (OA) is known as the "wear-and-tear" kind of arthritis, OA is a chronic condition characterized by the breakdown of the joint's cartilage. Cartilage is the part of the joint that cushions the ends of the bones and allows easy movement of joints. The breakdown of cartilage causes the bones to rub against each other, causing stiffness, pain and loss of movement in the joint. Osteoarthritis is known by many different names, including degenerative joint disease, ostoarthrosis, hypertrophic arthritis and degenerative arthritis. The cause is still not completely known and there is no cure. In fact, many different factors may play a role in whether or not you get OA, including age, obesity (increases mechanical stress), injury or overuse and genetics. OA could be caused by any one or a combination of these factors. Osteoarthritis most commonly occurs in the weight-bearing joints of the hips, knees and lower back. There are several stages of osteoarthritis: 1. Cartilage loses elasticity and is more easily damaged by injury or use. 2. Wear of cartilage causes changes to underlying bone. The bone thickens and cysts may occur under the cartilage. Bony growths, called spurs or osteophytes, develop near the end of the bone at the affected joint. 3. Fragments of bone and cartilage float in the joint fluid causing irritation and pain. 4. The joint lining, or the synovium, becomes inflamed due to cartilage breakdown causing cytokines (inflammation proteins) and enzymes that damage cartilage further. Deterioration of cartilage can: ? Affect the shape and makeup of the joint so it doesn't function smoothly. This can mean that you limp when you walk or have trouble going up and down stairs. The following was stated in my appeal letter, "I have terrible pain in my knees when I have to climb stairs". ? Mean the joint fluid doesn't have enough hyaluronan, which affects the joint's ability to absorb shock. Lifestyle modification, particularly weight reduction and maintaining an ideal body weight, is a core component of the management of osteoarthritis. This appears to be particularly true for weight-bearing joints (i.e., hips, knees) in females. I have been treating my arthritis with 100 MG daily of the prescription medication Diclofenac Sodium since October 2003. Diclofenac Sodium is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve symptoms of osteoarthritis and rheumatoid arthritis. This medication works by blocking the enzyme in your body that makes prostaglandins. Decreasing prostaglandins helps to reduce pain and swelling. Hypertension On May 23, 2006 my blood pressure was 112/80 and my glucose was normal at 93. I have no record of a glucose test for May 23, 2006. It is possible that a low blood pressure reading may be a side effect from the prescription medication Zoloft that I take for depression. Although, my medical records do indicate that my blood pressure has increased from May to December 2006. Blood pressure and pulse readings: May 9, 2006 102/84 85 May 23, 2006 112/80 80 November 22, 2006 120/82 76 December 29, 2006 124/78 82 Glucose Readings The clinic note dated May 9, 2006 listed the diagnose of impaired fasting glucose and the medication list included Metformin 1000mg per day. A two-hour PC glucose on May 15, 2006 was 119, with the normal range of 70 - 140. I have no record of a glucose test for May 15, 2006 Glucose Readings: August 16, 2004 Normal 93 Reference Range (70 - 99) May 25, 2006 High 103 Reference Range (70 - 99) Pre-diabetes range is (100 - 125) indicating that I have pre-diabetes. January 3, 2007 High 115 Reference Range (70 - 99) Pre-diabetes range is (100 - 125) indicating that I have pre-diabetes. Glucose 2-Hour PC Readings: May 25, 2006 Normal 119 Reference Range (Less than 140) Liver Condition My SGPT (ALT) Alanine Aminotransferase lab results have increased over the last months giving concern to the condition of my liver. This enzyme, unlike the other enzymes, which are produced in other cells besides the liver (such as lung, kidney and muscle), SGPT is found mainly in the liver. If this level is high, it is strongly suggested that liver disease may be present. Nonalcoholic fatty liver disease (NAFLD) refers to a wide spectrum of liver disease ranging from simple fatty liver (steatosis), to nonalcoholic steatohepatitis (NASH) to cirrhosis (irreversible, advanced scarring of the liver). The NAFLD spectrum is thought to begin with and progress from its simplest stage, called simple fatty liver. That is, fatty liver is the initial abnormality in the spectrum of NAFLD. Fatty liver has also been described in several medical syndromes. Fatty liver occurs in polycystic ovarian syndrome, in which polycystic ovaries are associated with obesity, excessive hair (hirsutism) and insulin resistance. Simple fatty liver involves just the accumulation of fat in the liver cells with no inflammation or scarring. The next stage and degree of severity in the NAFLD spectrum is NA**** resembles alcoholic liver disease, but occurs in people who drink little or no alcohol. The most frequent biochemical abnormality in the blood in NASH is persistent mild to moderately elevated transaminases (ALT) and (AST). In studies of patients undergoing stomach (gastric) reduction operations for morbid obesity, substantial weight loss is accompanied by a marked reduction in transaminases and a regression of fatty liver. The major feature in NASH is fat in the liver, along with inflammation and damage. NASH can be severe and can lead to cirrhosis, in which the liver is permanently damaged and scarred and no longer able to work properly. NASH is typically a disease of middle-aged overweight women with predominantly central (abdominal) fat distribution. Many people with NASH have diabetes or pre-diabetes. Strong evidence supports the concept that the process common to all stages of primary fatty liver disease is insulin resistance. It is important to stress that there are currently no specific therapies for NA**** has been shown that as the BMI increases, so does the amount of fat in the liver. The most important recommendations given to people with this disease is to reduce their weight, if they are obese. A major attempt should be made to lower body weight to a healthy range. Weight loss can improve liver tests in people with NASH and may reverse the disease to some extent. Liver Condition Continued: SGPT (ALT) Enzyme Readings: August 16, 2004 Normal 18 Reference Range (5-31) May 25, 2006 Normal 27 Reference Range (5-31) January 3, 2007 High 38 Reference Range (5-31) My SGOT (serum glutamic oxaloacetic transaminase), or aspartate aminotransferase, (AST) lab results have also increased over the last months. The enzyme SGOT is found in high concentration in the heart and liver and in moderately large amounts in the skeletal muscle tissues, kidneys and pancreas. After myocardial injury, the SGOT level rises within 6 to 10 hours, peaks at 12 to 48 hours, and returns to normal in approximately 3 to 4 days. A characteristic rise in SGOT levels occurs in more than 95% of patients with proven myocardial infarction. When body tissue or an organ such as the heart or liver is diseased or damaged, additional AST is released into the bloodstream. The amount of AST in the blood is directly related to the extent of the tissue damage. After severe damage, AST levels rise in 6 to 10 hours and remain high for about 4 days. SGOT (AST) Enzyme Readings: August 16, 2004 Normal 22 Reference Range (10-40) September 19, 2006 Normal 37 Reference Range (10-40) January 3, 2007 Normal 37 Reference Range (10-40) Yeast Infections Due to the excess weight that I carry, I have also been diagnosed with intertrigo and frequently get yeast infections under my breasts and under my abdomen. Intertrigo is a yeast infection of skin folds caused by Candida albicans. In areas of the body that have skin touching skin such as under heavy breasts or fat folds, the environment is warm and moist. This is the perfect environment for Candida albicans, a yeast that is normally found on the skin, to overgrow and cause symptoms. Intertrigo is characterized by an intensely red, macerated, glistening rash with scaling on the edges. The edge of the rash extends just beyond the limits of the opposing skin folds. Satellite lesions, small areas of the same rash that are close to the main rash, are characteristic of intertrigo and other Candida skin infections. Intertrigo is treated with antifungal creams such as clotrimazole which I have been using since November 2003. Clotrimazole is an antifungal and corticosteroid combination used to treat skin infections. It also relieves redness and itching associated with infections. The most preventative measure involves reducing skin to skin contact by weight loss to reduce the size of fat folds. In the summary statement of my summarized statement dated January 16, 2007, it is stated "The Prior authorization was denied because there was no documentation of a comorbid condition that was life threatening to the patient and unresponsive to appropriate treatment. The provider was referred to the prior authorization guidelines for gastric surgery of exogenous obesity. I find the words "exogenous obesity" to be unsubstantiated. The definition of Obesity, Exogenous is: Overweight caused by consuming more food than the person's activity level warrants, leading to increased fat storage. As I stated in my appeal letter "Many obese women do not overeat. It is a fact that when you are insulin resistant your body converts every calorie it can into fat, even if you are dieting. The result is that while the body is gaining weight, the energy cells are actually starving". Thank you for your time and for allowing me to provide you with this additional information. Kelly Knaack Once again I was denied. I have until March 22 to appeal again. Is there anything else that I can do to prove my case, or should I give it up?

Hi Kelly DON'T GIVE UP!!!!!!! That is just what the insurance company is hoping you would do. They love to play their little games. I think it's almost a test to see how determined you are to have this surgery. Don't let them break you. Show them you mean business. You are allowed a day of depression but then get right back on the saddle and fight for what is yours.....the right to live a healthier, happier life. Send in the letter you wrote but first call them and see if their is any information missing that they needed for approval. If they need something more from your doctors, get busy and find everything possible to plead your case. I've heard of this happening several times and the appeal generally works. Don't let them bully you. You have a lot of stength in numbers and everyone here at OH are standing behind you!!! Hang in there. You can do it!!! Jolene