read my appeal letter!

Please read my appeal letter for revision surgery before I send it....i welcome critiques: Dear CIGNA Healthcare National Appeals Unit, I am writing in response to your denial of needed revision medical surgery scheduled for myself. CIGNA states that weight loss surgery is not covered in my plan without prior approval, but this, in fact, is not what I am seeking. I have already had weight loss surgery in 2000 with another Insurance carrier. This is much needed revision surgery to fix specific malfunctions from the original surgery. I had a laproscopic RNY at Baystate Medical Center in Springfield MA in 2000 with Drs. Earl and Munshi. I was the first patient to ever have this done laproscopically with this surgical group. The 90 minute surgery procedure took 9 ½ hours and there were major complications. I lost 90 pounds in 6 weeks due to being unable to eat or drink anything at all. My hair and all but 3 teeth fell out due to malnutrition and constant vomiting. (50 times daily for months) I was admitted to the emergency ward several times due to malnutrition and dehydration and had to have an emergency endoscopy and an angioplasty performed to reopen the entrance to my pouch as it was completely shut. Due to my weakened state, my blood pressure dropped to dangerous levels and I had to be removed from anesthesia and have the procedure performed very quickly while I was awake. Because of this emergency situation, the procedure was compromised and the entrance was opened too large. After years of seeing my weight rise even after this weight loss surgery, extreme dieting and exercise, I have finally confirmed with 3 separate bariatric surgeons that the procedure failed and must be revised for my continued health. Dr. Earl, from Baystate Medical in Springfield, MA, Dr Kelly from U Mass Medical in Worchester, MA and Dr Carlos Barba in St. Francis Hospital in Hartford, CT all agree on this point. I had exhaustive testing to determine the problem, including an upper GI, lower bowel and blood tests, among others. It has been confirmed that the pouch was made 2 to 3 times too large and the entrance was opened too large during the emergency procedure, thus, in essence, having any food I eat drop right through my pouch and settle in my intestines creating 2 separate problems. No feeling of fullness and food is being absorbed at a higher rate than if I had never had the surgery at all. I am told that nothing I do will stop this process with out revision surgery. My health is continuing to erode as I wait to have this revision procedure performed. I have a herniated incision and all of the weight related co-morbities that I had prior to WLS have returned. I am a 46 year old morbidly obese male who is 5'6"tall and weigh 227 lbs., giving me a body mass index of 37 and it is continuing to climb. The body mass index is calculated by dividing a person's weight in kilograms by their height in meters squared. When a man's BMI is over 27.8, or woman's exceeds 27.3, that person is considered obese. The degree of obesity associated with a particular BMI ranges from mild obesity at a BMI near 27, moderate obesity at a BMI between 27 - 30, severe obesity at 30 - 35, to very severe obesity for patients with a BMI of 35 or greater. Therefore, I am classified as being very severely obese. The annual number of deaths in America attributable to obesity has been estimated to be 300,000 deaths per year. With my abnormally high BMI, I am at an estimated 190 percent increased risk of death at my present weight. I am having significant adverse symptoms from my return to obesity. I have difficulty standing. I have difficulty performing my daily activities, and in participating with my family in recreational activities. I have arthritis and pain of my weight-bearing joints. An increase in body weight adds trauma to weight bearing joints and excess body weight is a major predictor of osteoarthritis of the knees. This is a mechanical problem and not a metabolic one. Weight loss will markedly decrease the chance of developing osteoarthritis. I also suffer from shortness of breath. There are several abnormalities in pulmonary function in obese individuals. At one extreme are patients with so-called Pickwickian syndrome, or the obesity-hypoventilation syndrome, which is characterized by somnolence and hypoventilation; it eventually leads to corpulmonale. In patients who are less obese, there is a fairly uniform decrease in expiratory reserve volume and a tendency to reduction in all lung volumes. A low maximum rate of voluntary ventilation and venous admixture is also present. As an individual becomes more obese, the muscular work required for ventilation increases. In addition, respiratory muscles may not function normally in obese individuals. Because of my acid reflux and pains and aches in my back and legs I have difficulty sleeping, and therefore, am fatigued and tired during the day. This surgery usually cures acid reflux and sleep disturbances. I have borderline hypertension at this point. Hypertension is a common concomitant of obesity. I now have bone spurs on both my feet that are aggravated by my weight. I have spent all my adult life trying to lose weight. I am now at the very edge of complete disability and am at a point where everything is an effort. The obese individual has functional impairment in the activities of daily living. This dysfunction impacts sleep, recreation, work and social interactions. Economic costs of Obesity: 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. Indirect costs: 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 this case, are not effective. Rather it can expected that I will continue to gain weight and the costs of co-morbid conditions, including the ones I have regained and ones I surely will acquire as time goes on, will far outweigh the costs of revision surgery that I am asking you to please approve at this time. I look forward to be hearing from you at your very earliest convenience. Sincerely, Gary Smith Reference Sources: 1. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Institute of Medicine, National Academy of Sciences. 1995; 50-51. 2. Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell, S.M. Increasing prevalence of overweight among US adults. Journal of the American Medical Associatio*****; 272:205-211. 3. Troiano, R.P., Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell, S.M. Overweight prevalence and trends for children and adolescents: The National Health and Nutrition Examination Surveys, 1963 to 1991. Archives of Pediatrics and Adolescent Medicine,1995; 149:1085-1091. 4. Daily dietary fat and total food-energy intakes: Third National Health and Nutrition Examination Survey, Phase I, 1988-1991. MMWR Morbidity and Mortality Weekly Report. 1994; 43:116-117, 123-125. 5. Weight control: What works and why. Medical Essay. Mayo Foundation for Medical Education and Research, 1994.

Wow some ride.... I am in the same boat.... a little different situation, here is my appeal letter. and if this or yours is able to help someone else go for it. Dear Sir or Madam: I am writing to ask you to reconsider your decision to deny my surgery scheduled for January 18, 2005. While my policy does not carry the obesity rider I would like to mention that I am not having weight loss surgery. I had a gastric bypass in 1998, with much success I might add. I need this surgery to correct a few health problems that have occurred since then. Since 1998, I have had very few health problems. Now, however, I constantly suffer from stomach pain, which resemble that of a hernia but my Ct Scan does not reveal a hernia. In approximately 2002, I had a hernia repair. Pre op testing requested by Dr. Boustany entailed an upper GI Series as well, to ensure that the staple line was intact. The x-ray tech told me that my staple line was still in tact and that the pouch was still relatively small. Now 2 years later, I have stapleline disruption and H Pylori, the bacteria known to cause stomach ulcers, which was discovered during some tests ordered by Dr Boustany. Well, it seems that the H pylori bacteria manifested itself along the staple line, hence, causing staple line disruption as well as irritation along the stapleline. If the bacteria had manifested itself anywhere but the staple line and/or caused an ulcer that needed repair, the surgery would not be considered a weight loss issue. This is a medical need necessity not an elective surgery. I did not elect to have pains in my stomach. I did not elect to consume antibiotics (tetracycline) that made me sick for 2 weeks because I am allergic to them. I did not elect to get an ulcer. The long and short of this is that I do not need weight loss surgery. I have been there done that. Would any of you consider eating feces? Would you swim in raw sewage? While the answer to that is simple; the answer to let me have this surgery is a difficult one for you. You find it perfectly acceptable to allow my intestines to back up into my stomach. This is NOT a weight loss issue. With out the surgery, the H pylori bacteria may return. So what makes it ok to consider this an ""elective surgery for weight loss" covered under an obesity rider? I will continue to get stomach infections as a result of the bacteria. I will have to take costly antibiotics again in the future. No doubt making me ill and causing me pain in my stomach. I hope you consider this appeal and approve it based on a medical necessity. I am not asking to be treated for obesity. Please remember I had weight loss surgery in 1998, my insides are already bypassed so there for this can not really be considered a bypass can it? I just want to stop feeling sick and stop having stomach pain. So please, reconsider your decision based on these issues. Thank you in advance for your time. Very truly yours, Tina M. Blair

Gary, great letter with a ton of facts. May I offer a few points? 1. It is too long for a reviewer. They like short and to the point otherwise they will most likely ignore most of it. I would highlight the failure of the surgery and the fact that 3 independent (use that word) surgeons have agreed that you need a revision. 2. I would delete the explanation of BMI (they know what it means). 3. I would downplay the problems you have with gaining weight. First, you don't want to highlight that this is indeed for weight loss (when it is boiled down). The other reason is that while these things are so important to you, they are relatively mild conditions to the insurance company and not very compelling. 4. I would list your comorbidities without personal comments - again just the facts. 5. I assume you are attaching supporting documentation from your medical doctors including the independent evaluations. I hope you don't find these comments negative - I have done medical billing for 18 years (and teach at a community college) and have some experience here. I assume this is the first step in the appeals process? Good for you for fighting it and don't give up hope.

I'm in the same boat. Waiting for my denial letter. Ins. co. told surgeon it was denied. They too are making as if I am going for Gastric Bypass. I am not. I'm going to fix the Gastric Bypass. I will review your appeal letters and make my own up. Good luck with the appeals.