DS Appeal Letter - Show & Tell
I have had many people PM wanting to see my appeal letter. According to BCBS of IL policy I did not qualify for the DS as my BMI was under 50 and I had Z E R O qualifying comorbids. I truly believe that a thoughtful, well educated argument for the DS helped tremendously with the very quick overturn of my denial. Did I mention I had already been through the approval process for the RNY? and that I had been denied for that previously as well? :) Also, since my appeal letter was written, I noticed that I didn't need to lose 170 pounds... only 150 (because of my height) for a normal BMI hehe I have since altered my tracking.
Along with this letter that I overnight Fed Ex'ed straight to the appeals department, I attached over 80 pages of supporting data with color coded paper clips (I am so anal) I made sure to highlight and red ink the most important details of these studies. NO, I do not have many of these saved on my computer as my old hard drive has flopped, but I have trying to collect these again. I did, however, print a second hard copy of EVERYTHING I sent to appeals. ALWAYS make a copy of everything you send in to the insurance companies as they tend to lose things... a lot.
April 27,2010
Appeals Dept
BCBSIL
PO BOX 805107
Chicago IL 60680-4112
Dear Sir or Madam:
My name is XXXXXX. I am 37 years old, 5’ 10.5" tall and weigh 334 pounds. I have a current BMI 47.1. I am submitting this letter and extensive supporting data in appeal to my recent denial for Biliopancreatic Diversion with Duodenal Switch also referred to as BPD/DS.
To start off, I am fully aware of BCBSIL’s simple requirement of a 50 BMI to qualify for the BPD/DS. At my current weight of 334, I am a mere 10 pounds shy of a 50 BMI. I have read that a 50 BMI usually indicates 150 pounds overweight. Because I am slightly above average in height, I need to loose a minimum of 162-167 lbs to reach a goal weight of 165-170 lbs. 170 pounds is the highest BMI range of normal weight, but it is a healthy weight. I am not looking to become a model as you can tell. I am sure you can imagine the frustration this brings me. But here I am, ready to defend having this surgery and gain approval without having to do something as petty as gaining 10 pounds to qualify for a surgery that is far superior to the RNY. Ten pounds should not be the deciding factor in my individual case and I pray that you will look at the data, the DS lifestyle and most importantly my personal wishes for how I’d like to spend the rest of my “altered" life.
I have been in this process of researching and completing the requirements of bariatric surgery for quite some time. I have already been approved to receive the RNY surgery through BCBSIL. During that time I really mourned having to go the way of the RNY. I had some growing concerns about various aspects of it. The vomiting, the ‘foamies’, the dumping, the micro food portions, strictures, ulcers, stoma stretching, the blind stomach, the absence of the very important pyloric valve, the inability to take NSAIDS and time released medications and the statistics, a 41.7% failure rate for those at or above a 50 BMI. This is the ‘nutshell’ version of why I want to change the procedure to the BPD/DS.
Before seeking BPD/DS with Dr Sudan, I was working with RNY surgeon, Dr Roc Baumann at Carolina Weight Loss Surgery in Concord NC. I was really displeased with the treatment I received from his office so I decided to take my business elsewhere. It didn’t take long for me to find out that RNY doctors are a dime a dozen. Then I found out about Dr Sudan, a respected teaching surgeon with Duke University. He came to North Carolina from Creighton University in Nebraska. I am thrilled that we have such a talented surgeon in our state that performs BPD/DS without me having to travel to Georgia or Tennessee as many other North Carolinians have done in the past.
Dr. Sudan has performed approx 400 BPD/DS. Of those he has performed approx 120 using the Da Vinci Robot. In 2000, Dr Sudan pioneered the Da Vinci robot technology in its use for BPD/DS. Using robotics, he found there was a much lower incidence of morbidity and no mortality in his study. With the well documented experience of Dr Sudan and his pioneering of using robotics for this complicated surgery, this is in part why I am seeking to have the BPD/DS with Dr Sudan specifically. See paper B and C for more data.
There are quite a few reasons I believe this surgery is best for me.
First, as far as qualification goes, I am bumping up against the 50 BMI mark anyway. I might not be exactly 50 BMI today but being only 10 pounds shy I could bet that at some point it would be inevitable that I might gain that weight…especially if I go back on yet another diet. I usually loose 30-40 and then gain it all back plus 10 lbs. Dr Sudan and I both agree that while 50 BMI is used by studies to identify Super Obesity, other factors should also take place such as amount of weight needed to lose, and the personal choice of the patient as it is I, not the insurance company, that will have to live with this choice of surgery for the rest of my life. The denial letter also made reference to “conservative measures" but makes no specific detail in the policy or denial letter what that means exactly. I have been on every diet imaginable. Atkins, Slim Fast, Weigh****chers, The Zone, Lean Cuisine, diet teas, herbs and OTC pills. I have and use my YMCA membership for that last 10 years. I have countless work out videos. How much more conservative can it get? Also, in my last approval process for RNY I completed the required BCBSIL 3 month diet. As you can see, surgery was definitely not my first option. Indeed I have saved it as the last resort. Exactly how does one conservatively lose and keep off 170 pounds?
Secondly, because surgery is my last resort, I feel I should have the surgery that I believe is superior to the RNY. With my supporting data it’s very clear that the BPD/DS is preferred to RNY because starting at around 50 BMI the RNY becomes more and more ineffective. A 41.7% chance of RNY failure scares me. I do not ever want to face having a revision surgery in the future if the RNY is going to more than likely fail me at my high BMI. The BPD/DS clearly offers better weight loss results, and it keeps weight regain down year over year versus the RNY. The studies show long term patients who achieve and maintain 50% EBWL are far higher in DS patients that RNY (@36 months 84.2% versus 59.3%) And remember a 50 BMI indicates one is 150 pounds over normal weight. I need to lose about 170 pounds to reach the top of the normal BMI scale. Packet A offers a lot of relevant information to this subject.
Next, let’s consider the actual procedure itself. I know the DS is a more complicated surgery. Not just anyone can perform it (unlike the RNY). The surgery takes longer and usually requires one extra day in the hospital. I hope this all does not boil down to a few extra dollars BCBSIL doesn’t want to spend. Back to the process… I have a lot of concern about the RNY pouch. I do not like the idea of reconstructing a pouch from the stomach. I do not like the thought of having a blind stomach that cannot ever be scoped if there is a fear of ulcers, cancer etc. I wholeheartedly disagree with the permanent removal of the pylorus. I would rather not live with the fear of stretching out a man made stoma because it can’t control emptying. The pyloric valve is extremely important to leave fully intact! With BPD/DS, I can KEEP my natural stomach. Yes, I understand that a large portion will be removed, but the basic function of the smaller stomach truly remains the same. Food will stay in my stomach longer so that I might gain more nutrients from it. I would not have to worry about dumping, or food getting stuck. Stricture and marginal ulcers would also be very less likely. The malabsorption in the intestines is something I know I can “live with" a lot better than a pouch. I also know that it will aid in keeping the weight off long term. I am fully aware that potty issues may abound, but this can be controlled with proper diet and is certainly a lesser evil than the RNY.
I am also trying to be mindful of the fact that this surgery will follow me for the rest of my life. I want to do this right the first time! “Think twice, cut once" as they say. I need to consider my future and the fact that I might need to have certain medications that would otherwise be prohibited with RNY, even something as simple as NSAIDS or a time released med. Sure, I’m young now and I take a lot of Advil now for 2 knee injuries, plantar faciitis in both feet…. but what about when I’m 70 and I inherit the family arthritis or any other ailments. I DO NOT want to depend on STEROIDS as an alternative. I do not do well with steroids. I am trying to take into account what my needs might be 30-40 years down the road, not just the here and now. And that’s exactly what the RNY does, it addresses the here and now with it’s super fast weight loss during a short honeymoon period. So, after that, then what? I’m stuck with an operation that no longer meets my needs and with stretched pouch and stoma that will require revision, banding or simply face the weight regain.
Finally, and most importantly, I am looking at this as a quality of life issue. I have suffered. Whether it’s the never ending dieting, the looks I get on the street, the aches my body is always experiencing, I have been suffering for years. To me, the RNY is like the final punishment. Always having to cut food to the size of an eraser, then chewing it forever and still having fear that it will get stuck. Or the awful punishment that dumping brings. I have heard stories from friends that had to stop their car and lay on the roadside until the dumping subsided. I don’t want a surgery that is going to make me feel even more guilt about food. And I don’t want to face regain a few years down the road when the RNY honeymoon is over. I want to be free of that and I believe the BPD/DS will give me a second chance. While I know I could not eat everything I want, my food variety will be much wider. I will be able to eat a normal, small sized meal of 4-6oz compared to 1-2oz with RNY. I would be able to eat high quality dense proteins, not just drink it in the form of shakes. I am willing to commit to a strict vitamin regimen, to eat 90-100g of protein per day and to have regular follow ups with my doctor. Simply put the DS would allow me to eat more like a normal, healthy person.
I have printed and highlighted some of the information that I have been studying for the last 6 months. Please thumb through these and at least read the parts I have highlighted. I submit these as part of my appeal so that you will now that I have not made this decision lightly. I am also submitting a new study (packet 1) that is about to be published that discusses the DS for patients UNDER 50 BMI. My surgeon, with all of his experience, has also indicated that the DS is a good surgery for those under 50 BMI. Looking at all of my info, he thinks I am a perfect candidate and with my being so very close to the BMI requirement, and my need to lose 170 lbs, I hope that you will agree as well.
Thank you for your time and consideration,
XXXXX XXXXXXXXXXX ~GG
on 7/28/11 6:42 am
This is amazing, and I just printed it off. I self paid for a band almost 4 yrs ago and I'm only down to 288 lbs. I still have so far to go, and I'm certainly not getting any younger.
My new health insurance only covers the lap band ( I suspect since I work for a hospital system that only has a band program). It never ceases to amaze me that insurance companies can't see the wisdom of paying for an effective WLS once rather than the on going costs of heart disease or diabetes I am sure to get as well as the crappy knees I have that I've already had an MRI, xrays, and a full round of physical therapy on.
Sigh.
Join me here: weightlosssurgery.proboards.com/
My DS!Within 10 days, huh? I'll probably have to appeal mine... BCBSNC. So, I've already bookmarked this threat. :p
Join me here: weightlosssurgery.proboards.com/
