Denied a referral for not having 6 mo. phys doc. diet
I also had to have 6 month diet and didn't have it before initial meeting with surgeon. But thanks to OH, I knew about it and had talked with PCP.
You will need to see your PCP once a month and the reason has to be for your weight/diet. Most insurance companies would like to see you lose but if your Dr documents that you are trying and how you tried, that is the important thing.
I used Weigh****chers and took my card into each visit. You can log your food and take that with you.
See the thing is the insurance companies and some surgeons don't want to waste their time with people who aren't willing to at least try to follow a program. I am not saying that is you but there are folks out there that want the magic wand.
Good Luck
You will need to see your PCP once a month and the reason has to be for your weight/diet. Most insurance companies would like to see you lose but if your Dr documents that you are trying and how you tried, that is the important thing.
I used Weigh****chers and took my card into each visit. You can log your food and take that with you.
See the thing is the insurance companies and some surgeons don't want to waste their time with people who aren't willing to at least try to follow a program. I am not saying that is you but there are folks out there that want the magic wand.
Good Luck
Highest 360 Surgery 333 Current 168 Goal 150
BMI Highest 65.8 Current 32 Height 5'2"
Hernia Repair/TT 9.23.08
On February 19, 2009 at 5:47 AM Pacific Time, CarolynK wrote:
I also had to have 6 month diet and didn't have it before initial meeting with surgeon. But thanks to OH, I knew about it and had talked with PCP. You will need to see your PCP once a month and the reason has to be for your weight/diet. Most insurance companies would like to see you lose but if your Dr documents that you are trying and how you tried, that is the important thing.
I used Weigh****chers and took my card into each visit. You can log your food and take that with you.
See the thing is the insurance companies and some surgeons don't want to waste their time with people who aren't willing to at least try to follow a program. I am not saying that is you but there are folks out there that want the magic wand.
Good Luck
Lisa
pineview01 has deleted this message.
In California, you can get that overturned by the Independent Medical Review board. You can get them to cover the duodenal switch if your insurance wants to say it's not a covered procedure. Speaking of which, with 200 lbs to lose, I highly recommend you give the switch a look. Check out dsfacts.com and duodenalswitch.com.
Valerie
DS 2005
There is room on this earth for all of God's creatures..
next to the mashed potatoes
On February 19, 2009 at 6:01 AM Pacific Time, Valerie G. wrote:
In California, you can get that overturned by the Independent Medical Review board. You can get them to cover the duodenal switch if your insurance wants to say it's not a covered procedure. Speaking of which, with 200 lbs to lose, I highly recommend you give the switch a look. Check out dsfacts.com and duodenalswitch.com. Lisa
Start that diet now. Have your doctor start documenting your weight as of your last visit where you were weighed. Get a diet sheet from him NOW.
You can appeal while getting things rolling to have that diet done in 6 months. It will pass faster than you can imagine.
I saved my money for several years to pay cash for my surgery and flew to India to be able to afford to have it. So you can do 6 months!
Good luck and go for it.
You can appeal while getting things rolling to have that diet done in 6 months. It will pass faster than you can imagine.
I saved my money for several years to pay cash for my surgery and flew to India to be able to afford to have it. So you can do 6 months!
Good luck and go for it.
In the state of CA you do not have to do the medically supervised diet. The supervised diet is just a hoop and stall tactic that IPA and insurance use to delay or prolong patients getting WLS. If you've already received your denial letter then appeal directly to your insurance now. They have 30 days to respond to your appeal. If they do not give you an answer to your appeal within the 30 days then on the 31st day call up the CA Dept. of Managed Health Care (DMHC) http://www.dmhc.ca.gov/ and file a grievance with them based on not getting the referral because of the 6 month supervised diet. If your insurance denies you too based on this criteria call up the DMHC and file a grievance when you receive that denial letter. The DMHC has a peer review on this very subject. Here is the link: include this in your appeal letter
http://www.dmhc.ca.gov/aboutTheDMHC/org/boards/cap/Bariatric REV.pdf
SUMMARY CONCLUSION There is no literature presented by any authority that mandated weight loss, once a patient has been identified as a candidate for bariatric surgery, is indicated. There is a mixture of results that question whether weight or truncal obesity is a risk factor for complications after bariatric surgery. The more analytic studies have not found that body mass index (BMI) or total weight is an independent risk factor for complications or death from bariatric surgery.
No institution that has recently published data on bariatric surgery describes a protocol requiring weight loss between identification of the need for surgery and the surgery. Many institutions in California have published results of surgery with particular focus on factors that contribute to morbidity and mortality. No paper from a California institution mentions mandated weight loss before bariatric surgery. Nor does any literature regarding the treatment for the morbidly obese recommend continued weight loss during the period between identification of the need for bariatric surgery and the surgery.
Mandated weight loss prior to indicated bariatric surgery is without evidence-based support. Mandated weight loss prior to indicated bariatric surgery leaves the patient at increased risk from the patient’s comorbidities. Mandated weight loss prior to indicated bariatric surgery is not medically necessary. Mandated weight loss prior to indicated bariatric surgery would be deviant from the standard of care practiced in the United States and other published countries. The risks of delaying bariatric surgery, while not entirely known in the short-term, are real and can be measured. Any potential value of losing weight prior to bariatric surgery is theoretical and not supported by any data. An experimental study including fully informed consent to determine if there were a reduction in risks or other benefit from mandated weight loss prior to bariatric surgery is indicated.
IMR Decisions from the DMHC:
Ref ID #MN07-7341
Reviewer's Findings:
A 45-year-old female has requested gastric bypass surgery without first completing the Medical Group’s six-month supervised dietary counseling program for treatment of morbid obesity. Findings: The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a high BMI and co-morbidities that will likely be ameliorated or eliminated by bariatric surgery. With regard to the preoperative dietary counseling program, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for these patients. In addition, recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese. The psychological evaluation indicates the patient is an appropriate candidate for the gastric bypass procedure.
http://wp.dmhc.ca.gov/imr/detail.asp?id=7341&optFormat=html& cboDetermination=Overturned+Decision+of+Health+Plan&cmdSearc h=Search&cboMC=Morbid+Obesity&cboTreatment2=0&cboDiagnosis2= 0&cboDT=0&cboType=0&txtDetails=supervised+diet
Ref ID #:MN05-4907
Reviewer's Findings:
The patient is a 58-year-old female who is 64 inches tall, weighing 321 pounds with a body mass index (BMI) of 55.1. She is requesting authorization for gastric bypass surgery. The patient has hepatitis C and other significant comorbid conditions. The patient outlines a significant history of family obesity and attempted weight loss both through supervised and unsupervised diet plans. The patient completed a psychological evaluation and it was recommended that she see a therapist both before and after gastric bypass surgery. With a BMI of 55.1 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Moreover, regarding the patient’s psychological status, the NIH recommends psychological screening for those with eating disorders. This patient has completed a psychological evaluation, which found her in good mental health, well informed about the proposed surgery, and in a stable living situation. The patient should follow through on the recommendation to see a therapist both before and after bypass surgery. Based upon the information set forth above, I have determined the requested surgery is medically necessary for treatment of the patient’s medical condition. The Health Plan’s denial should be overturned.
http://wp.dmhc.ca.gov/imr/detail.asp?id=4907&optFormat=html& cboDetermination=Overturned+Decision+of+Health+Plan&cmdSearc h=Search&cboMC=Morbid+Obesity&cboTreatment2=0&cboDiagnosis2= 0&cboDT=0&cboType=0&txtDetails=supervised+diet
Are you sure you don't have sleep apnea? Do you snore? Do you have daytime fatigue and always feel tired? Have you had a sleep study? It really doesn't matter whether or not you have comorbids since your BMI is so high, but if you do snore it would be good to get a sleep study just in case you have sleep apnea.
With your high BMI have you looked into getting the DS (duodenal switch). The DS offers both malabsorption and restriction. You will lose more of your excess weight with the DS and keep it off long term because of malabsorption. With the DS you have a smaller yet fully functioning stomach so you do not have dumping, you can still take NSAIDS, you can eat more variety of foods, there are also other benefits to the DS. Check out the DS forum http://www.obesityhelp.com/forums/DS/ if you have questions or are interested.
You're very lucky to live in the state of CA and have the DMHC who oversees HMOs. They are very pro WLS. The process may be long but you are worth it. Never give up. If you meet NIH criteria for WLS and your HMO is based in CA you are almost guaranteed approval for WLS; this includes the DS.
http://www.dmhc.ca.gov/aboutTheDMHC/org/boards/cap/Bariatric REV.pdf
SUMMARY CONCLUSION There is no literature presented by any authority that mandated weight loss, once a patient has been identified as a candidate for bariatric surgery, is indicated. There is a mixture of results that question whether weight or truncal obesity is a risk factor for complications after bariatric surgery. The more analytic studies have not found that body mass index (BMI) or total weight is an independent risk factor for complications or death from bariatric surgery.
No institution that has recently published data on bariatric surgery describes a protocol requiring weight loss between identification of the need for surgery and the surgery. Many institutions in California have published results of surgery with particular focus on factors that contribute to morbidity and mortality. No paper from a California institution mentions mandated weight loss before bariatric surgery. Nor does any literature regarding the treatment for the morbidly obese recommend continued weight loss during the period between identification of the need for bariatric surgery and the surgery.
Mandated weight loss prior to indicated bariatric surgery is without evidence-based support. Mandated weight loss prior to indicated bariatric surgery leaves the patient at increased risk from the patient’s comorbidities. Mandated weight loss prior to indicated bariatric surgery is not medically necessary. Mandated weight loss prior to indicated bariatric surgery would be deviant from the standard of care practiced in the United States and other published countries. The risks of delaying bariatric surgery, while not entirely known in the short-term, are real and can be measured. Any potential value of losing weight prior to bariatric surgery is theoretical and not supported by any data. An experimental study including fully informed consent to determine if there were a reduction in risks or other benefit from mandated weight loss prior to bariatric surgery is indicated.
IMR Decisions from the DMHC:
Ref ID #MN07-7341
Reviewer's Findings:
A 45-year-old female has requested gastric bypass surgery without first completing the Medical Group’s six-month supervised dietary counseling program for treatment of morbid obesity. Findings: The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a high BMI and co-morbidities that will likely be ameliorated or eliminated by bariatric surgery. With regard to the preoperative dietary counseling program, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for these patients. In addition, recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese. The psychological evaluation indicates the patient is an appropriate candidate for the gastric bypass procedure.
http://wp.dmhc.ca.gov/imr/detail.asp?id=7341&optFormat=html& cboDetermination=Overturned+Decision+of+Health+Plan&cmdSearc h=Search&cboMC=Morbid+Obesity&cboTreatment2=0&cboDiagnosis2= 0&cboDT=0&cboType=0&txtDetails=supervised+diet
Ref ID #:MN05-4907
Reviewer's Findings:
The patient is a 58-year-old female who is 64 inches tall, weighing 321 pounds with a body mass index (BMI) of 55.1. She is requesting authorization for gastric bypass surgery. The patient has hepatitis C and other significant comorbid conditions. The patient outlines a significant history of family obesity and attempted weight loss both through supervised and unsupervised diet plans. The patient completed a psychological evaluation and it was recommended that she see a therapist both before and after gastric bypass surgery. With a BMI of 55.1 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Moreover, regarding the patient’s psychological status, the NIH recommends psychological screening for those with eating disorders. This patient has completed a psychological evaluation, which found her in good mental health, well informed about the proposed surgery, and in a stable living situation. The patient should follow through on the recommendation to see a therapist both before and after bypass surgery. Based upon the information set forth above, I have determined the requested surgery is medically necessary for treatment of the patient’s medical condition. The Health Plan’s denial should be overturned.
http://wp.dmhc.ca.gov/imr/detail.asp?id=4907&optFormat=html& cboDetermination=Overturned+Decision+of+Health+Plan&cmdSearc h=Search&cboMC=Morbid+Obesity&cboTreatment2=0&cboDiagnosis2= 0&cboDT=0&cboType=0&txtDetails=supervised+diet
Are you sure you don't have sleep apnea? Do you snore? Do you have daytime fatigue and always feel tired? Have you had a sleep study? It really doesn't matter whether or not you have comorbids since your BMI is so high, but if you do snore it would be good to get a sleep study just in case you have sleep apnea.
With your high BMI have you looked into getting the DS (duodenal switch). The DS offers both malabsorption and restriction. You will lose more of your excess weight with the DS and keep it off long term because of malabsorption. With the DS you have a smaller yet fully functioning stomach so you do not have dumping, you can still take NSAIDS, you can eat more variety of foods, there are also other benefits to the DS. Check out the DS forum http://www.obesityhelp.com/forums/DS/ if you have questions or are interested.
You're very lucky to live in the state of CA and have the DMHC who oversees HMOs. They are very pro WLS. The process may be long but you are worth it. Never give up. If you meet NIH criteria for WLS and your HMO is based in CA you are almost guaranteed approval for WLS; this includes the DS.
On February 19, 2009 at 7:26 PM Pacific Time, CaliMom wrote:
In the state of CA you do not have to do the medically supervised diet. The supervised diet is just a hoop and stall tactic that IPA and insurance use to delay or prolong patients getting WLS. If you've already received your denial letter then appeal directly to your insurance now. They have 30 days to respond to your appeal. If they do not give you an answer to your appeal within the 30 days then on the 31st day call up the CA Dept. of Managed Health Care (DMHC) http://www.dmhc.ca.gov/ and file a grievance with them based on not getting the referral because of the 6 month supervised diet. If your insurance denies you too based on this criteria call up the DMHC and file a grievance when you receive that denial letter. The DMHC has a peer review on this very subject. Here is the link: include this in your appeal letterhttp://www.dmhc.ca.gov/aboutTheDMHC/org/boards/cap/Bariatric REV.pdf
SUMMARY CONCLUSION There is no literature presented by any authority that mandated weight loss, once a patient has been identified as a candidate for bariatric surgery, is indicated. There is a mixture of results that question whether weight or truncal obesity is a risk factor for complications after bariatric surgery. The more analytic studies have not found that body mass index (BMI) or total weight is an independent risk factor for complications or death from bariatric surgery.
No institution that has recently published data on bariatric surgery describes a protocol requiring weight loss between identification of the need for surgery and the surgery. Many institutions in California have published results of surgery with particular focus on factors that contribute to morbidity and mortality. No paper from a California institution mentions mandated weight loss before bariatric surgery. Nor does any literature regarding the treatment for the morbidly obese recommend continued weight loss during the period between identification of the need for bariatric surgery and the surgery.
Mandated weight loss prior to indicated bariatric surgery is without evidence-based support. Mandated weight loss prior to indicated bariatric surgery leaves the patient at increased risk from the patient’s comorbidities. Mandated weight loss prior to indicated bariatric surgery is not medically necessary. Mandated weight loss prior to indicated bariatric surgery would be deviant from the standard of care practiced in the United States and other published countries. The risks of delaying bariatric surgery, while not entirely known in the short-term, are real and can be measured. Any potential value of losing weight prior to bariatric surgery is theoretical and not supported by any data. An experimental study including fully informed consent to determine if there were a reduction in risks or other benefit from mandated weight loss prior to bariatric surgery is indicated.
IMR Decisions from the DMHC:
Ref ID #MN07-7341
Reviewer's Findings:
A 45-year-old female has requested gastric bypass surgery without first completing the Medical Group’s six-month supervised dietary counseling program for treatment of morbid obesity. Findings: The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a high BMI and co-morbidities that will likely be ameliorated or eliminated by bariatric surgery. With regard to the preoperative dietary counseling program, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for these patients. In addition, recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese. The psychological evaluation indicates the patient is an appropriate candidate for the gastric bypass procedure.
http://wp.dmhc.ca.gov/imr/detail.asp?id=7341&optFormat=html& cboDetermination=Overturned+Decision+of+Health+Plan&cmdSearc h=Search&cboMC=Morbid+Obesity&cboTreatment2=0&cboDiagnosis2= 0&cboDT=0&cboType=0&txtDetails=supervised+diet
Ref ID #:MN05-4907
Reviewer's Findings:
The patient is a 58-year-old female who is 64 inches tall, weighing 321 pounds with a body mass index (BMI) of 55.1. She is requesting authorization for gastric bypass surgery. The patient has hepatitis C and other significant comorbid conditions. The patient outlines a significant history of family obesity and attempted weight loss both through supervised and unsupervised diet plans. The patient completed a psychological evaluation and it was recommended that she see a therapist both before and after gastric bypass surgery. With a BMI of 55.1 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Moreover, regarding the patient’s psychological status, the NIH recommends psychological screening for those with eating disorders. This patient has completed a psychological evaluation, which found her in good mental health, well informed about the proposed surgery, and in a stable living situation. The patient should follow through on the recommendation to see a therapist both before and after bypass surgery. Based upon the information set forth above, I have determined the requested surgery is medically necessary for treatment of the patient’s medical condition. The Health Plan’s denial should be overturned.
http://wp.dmhc.ca.gov/imr/detail.asp?id=4907&optFormat=html& cboDetermination=Overturned+Decision+of+Health+Plan&cmdSearc h=Search&cboMC=Morbid+Obesity&cboTreatment2=0&cboDiagnosis2= 0&cboDT=0&cboType=0&txtDetails=supervised+diet
Are you sure you don't have sleep apnea? Do you snore? Do you have daytime fatigue and always feel tired? Have you had a sleep study? It really doesn't matter whether or not you have comorbids since your BMI is so high, but if you do snore it would be good to get a sleep study just in case you have sleep apnea.
With your high BMI have you looked into getting the DS (duodenal switch). The DS offers both malabsorption and restriction. You will lose more of your excess weight with the DS and keep it off long term because of malabsorption. With the DS you have a smaller yet fully functioning stomach so you do not have dumping, you can still take NSAIDS, you can eat more variety of foods, there are also other benefits to the DS. Check out the DS forum http://www.obesityhelp.com/forums/DS/ if you have questions or are interested.
You're very lucky to live in the state of CA and have the DMHC who oversees HMOs. They are very pro WLS. The process may be long but you are worth it. Never give up. If you meet NIH criteria for WLS and your HMO is based in CA you are almost guaranteed approval for WLS; this includes the DS.
To me, the reason they are requesting that isn't to have me lose weight before the surgery but to a. stall me in hopes of me giving up and b. because I truly don't have documentation of dieting for years and years. So, in Ca this is not mandatory? If my appeal gets denied I will definately contact the DMHC. I don't believe I snore according to my best friend. I do get tired during day but I stay up late at night. I am going to request a sleep apnea test from my PCP. I will look up the criteria for the NIH. I assumed with my BMI I did. Thank you for your help, I appreciate it!Lisa
Decision Summary
The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is adequate to conclude that open and laparoscopic Roux-en-Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS), are reasonable and necessary for Medicare beneficiaries who have a body-mass index (BMI) > 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity.
https://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?from2=viewd ecisionmemo.asp&id=160&
The 1998 National Institutes of Health (NIH) Consensus Development Conference set forth guidelines stating that candidates for bariatric surgery include patients with a BMI ≥40 who have failed conventional weight loss attempts and are properly educated and motivated for surgery and patients with a BMI ≥35 who have comorbidities related to their obesity that are imminently life-threatening or causing severe lifestyle limitations. (Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults - the evidence report. National Institutes of Health. Obes Res 1998;6(Suppl 2):51S–209S)
NIH criteria for surgical considerations. General indications are as follows:
*. BMI ≥ 40 or ≥ 35 with significant co-morbidities,
*. Weight 100 pounds greater than ideal for height, sex, and age. (Weight greater than double ideal for patients with short stature),
*. Adequate comprehension by the patient of risks hazards of surgery, short and long term complications, either possible or anticipated, and understanding of the mechanism of how the surgery results in post-operative weight loss,
*. subjective evaluation of patient by attending physicians and surgeon
http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdfIn your appeal I think you should just stick to the facts:
*Cite the peer review from the DMHC, include copies of that along with the 2 IMR (independent medical review) decisions I gave you earlier.
*You should emphasis that you've been MO or SMO obese since whatever age and have tried and failed multiple diets. List the ones that you've done (if you have documentation all the better)
*Include a list of comorbids that you do have, family history of comorbids (i.e diabetes, heart diease, stroke, etc...)
*Provide a letter of medical necessity from your PCP and any other physicians you've seen or are in favor of you getting WLS
*You meet NIH criteria for WLS
*Medicare covers WLS for patients with BMI > 35 and comorbids and your BMI is almost twice that
*If you haven't done so already, you might want to consider getting your psych eval done now and including that with your appeal. It is a requirement no matter which surgery you choose. And if you do file a grievance with the DMHC it looks better if you have it done already and a psych doc says you're not crazy and understand the benefits and possible complications dealing with WLS
*Stick to the facts.
*Do not get defensive (yes I know hard not to do) you just need to get your point across that you are an informed patient and that you qualify for and need WLS. If you get the denial from the insurance contact the DMHC. If your insurance overturns your IPA denial all the better for you.
One last note (and sorry my posts are so long) continue the supervised diet with your PCP while you are going through the appeals process. All the medically supervised diet entails is your PCP weighing you and documenting everything you're "doing" to lose weight, diet, exercise, etc.... You do not need to pay for a nutritionist or WW or anything like that just see your PCP every month for 6 consecutive months. Make sure they note that you are there to discuss diet and exercise or weight loss plan, or wording similiar to that. For now just appeal about being denied the referral for the WLS consult then go from there.
Here is a very informative post by Diana Cox. It is a step by step guide on how to get DS approval (which I think is the best WLS out there) but you can use it as a general guideline for getting WLS approval.
http://www.obesityhelp.com/forums/DS/3515897/Insurance-says- DS-investigational-a-how-to-manual/
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