Magnacare denial due to Union controlled exclusion....Letters I sent what do you think?

The first letter I sent was forwarded to the medical director of magnacare, she inturn left me a message reiterating what I already knew, which was that the exclusion was controled by my union.(I got most of the first letter from this site) If anyone has gone thru this before please let me know if you think these letters are good enough. I write this letter to appeal your exclusion RNY gastric bypass surgery as part of our covered benefits in our insurance. (Diagnosis Code 278.01 Procedure Code 43847). I was referred for this surgery by my PCP, who is very concerned about my health because of severe morbid obesity. I am a 37 year old morbidly obese female who is 5" 3' tall and weigh 230 lbs., giving me a body mass index of 40.7. 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 40 or greater1,2,3. Therefore, I may be 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 year4,5. 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 obesity. Diabetes from insulin resistance Due to my weight .I take insulin as well as other medications to control my sugar. I am at risk for many diabetes related complications .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 cor pulmonale. 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 pains and aches in my back and legs I have difficulty sleeping, and therefore, am fatigued and tired during the day. I take medication for this. I suffer from hypertension at this point. Hypertension is a common concomitant of obesity. I also take medication for this. I have made many, many attempts to lose weight and this has gone on all my life. I was put on medications by my doctor to help lose weight. I have been put on medications over and over again. I would lose some weight then gain it all back, and more. I have also tried many exercise programs. I have tried Nutri-System. As you can see, 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 they will continue to gain weight and the costs of co-morbid conditions, including the ones I already have and ones I surely will acquire as time goes on, will far outweigh the costs of gastric bypass surgery that we are asking you to please approve for me. As you can see I have exhausted all the traditional ways to lose weight. The gastric bypass is an approved and proven means to permanently lose weight and cut the cost of the medical expenses that I will surely need if I do not loose this weight. Please approve this surgery for me. Thank you. Sincerely, Madeline Mojica CC: NJ Department of Banking & Insurance Health Insurance Bureau New Jersey Mandated Health Benefits Advisory Commission 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. _______________________________________________________________________ The second letter I wrote: Some time ago I wrote a letter requesting that the recommended surgery of gastric bypass be approved. After a few weeks, I was told by the office of the union that my letter had been forwarded to a Catherine Marino MD., at Magnacare. After speaking with a representative from Magnacare I received a voice mail from that representative stating that Dr. Marino claimed that, "The gastric bypass is an exclusion which is controlled by the Board of trustees." Once again I plead to the board of trustees that you approve this surgery. Gastric bypass is not an experimental procedure. Extraordinary advances have been made in the last few years that minimize the complications of surgery. Additional procedures have been put in place as to secure a carefully selected surgical candidate. Today patients are not only screened for psychological critera, but are also physically screened to ensure that there will be no preventable complications. Bariatric surgery is a life-saving procedure as it is proven to increase life expectancy ? Christou study compared morbidly obese patients who were treated with surgery versus those who were not. It found an 89% reduction in the risk of death throughout five years in the surgery group. In other words, those *****ceived surgery were nine times less likely to die over the next five years. 6 ? MacDonald study in North Carolina found 68% reduction in risk of death after mean follow-up time of six years. 7 ? Flum study found that adjusted hazard for death was 33% lower for patients *****ceived surgery than for non-operated patients. 8 Bariatric surgery resolves potentially fatal co-morbid conditions ? A meta-analysis study including more than 22,000 patients showed the following effects of surgery on co-morbidities: ˚ Diabetes was completely resolved in 76.8% of patients. ˚ High cholesterol was resolved or improved in more than 70% of patients. ˚ High blood pressure was resolved in 61.7% of patients. ˚ Sleep apnea was resolved in 85.7% of patients. 9 ? Other studies have shown even higher (82%) resolution of diabetes 10 and "profound improvement in obstructive sleep apnea." 11 Weight-loss post- surgery is extensive and durable ? A long term study following patients for up to 14 years after surgery found that 89% of weight-loss was maintained. 12 The risk-benefit tradeoff for bariatric surgery is favorable ? The mortality rate for bariatric surgery varies by surgeon. Experienced surgeons have mortality rates ranging from 0.5%-2% (averaging the rate for all types of procedures). The risks of not receiving surgery is far higher as demonstrated by the Christou study where those who did not receive surgery were almost nine times more likely to die. 13 Coverage for bariatric surgery makes economic sense ? Upfront costs of bariatric surgery are paid off in three and a half years due to hospitalization cost savings. 14 ? Post surgery drug costs for diabetic and anti-hypertensive medications decrease dramatically. Potteiger study found a 77.3% savings. 15 The procedures of to day have advanced significantly over the last few years. Yes, as in all major surgeries there is a chance of complications arising, but these chances are greatly reduced through careful patient selection and thru patient education. Following doctors orders making sure doctors are board certified and have extensive training and experience is key to avoiding complications. Just two emergency hospital visits that result in hospitalization will far exceed the cost of gastric bypass surgery. These visits can be prevented by lowering my weight thru gastric bypass surgery. I am not a doctor nor do I claim to be a medical expert but the evidence of what my doctors' claim is well documented and all backed by the American Society of Bariatric Surgery, American Society of Obesity, and American Society of Diabetes and by the US government. I am not looking for an easy solution to my weight problem, I am looking for a solution to diabetes, pcos, high blood pressure, back problems, joint problems, and high cholesterol and this by no means is an easy solution, No major surgery is, but this is my best option. I am too obese to exercise at this point, I have to many problems with my back that stem from my weight. My heart seems as it will explode if I walk more than 20 feet. I end up out of breath and afraid I will suffer a heart attack. Members of the board, as stated in our benefits package only you have right to make revisions to our benefits package. This procedure is medically necessary and I request that you reconsider and approve this procedure for me not only as a means for weight loss but as a means to control my diabetes, high blood pressure, high cholesterol, back and joint pain, and polycystic ovarian disease. Due to my medical problems I am at risk for, Heart attack Stroke Gangrene Cancer Arthritis Diabetic Complications All of which carry a hefty price tag to treat. Please consider this request. The annual cost of treating my co-morbidities will far exceed the cost of gastric bypass surgery. My co morbidities are as follows: Diabetes Managment: I currently take Lantus insulin plus, 800mg of Metformin a twice day. I must check my blood sugar levels twice a day. Supplies and medication covered by insurance. Lantus Insulin Syringes Alcohol Swabs One Touch Test Strips One Touch Lancets Frequent Check ups (at least 4 times a year) Emergeny Room Visits (at least 3 per year due to uncontrolled diabetes and its complications.) Blood Tests Regular feet exams This list does not include the possibilities of diabetes complications like: Vision loss, infections, colds that take longer to heal than normal colds. High blood pressure management: Fisnor 20 mg per day Blood pressure reading apparatus(which has not been ordered yet but will be ordered soon.) 2 to 4 office visits per year at least 2 Emergency room visits per year Polycystic Ovarian Disease Birth control Pills(as a means to have normal periods not to prevent pregnancy) Pain Medication At least Two visits to hospital per year for pain At least two visits to dr. office per year Back and Joint Pain at least 1 hospitalizations per year at least 3 to 4 office visits per year Pain management Pain medication Exrays MRI's Physical Therapy High Cholestrol Lipitor 20mg per day I know that the decisions made by the Board of trustees in regards to what to exclude is a decision based on the overall well being of the members, but the extreme cost of my current medical health problems will be markedly cut down if I have this gastric bypass surgery. According to Both of the Doctors, the day of the surgery my insulin and metformin medications will be reduced by half and with in the next few months the medication will be stopped completely, that means no more insulin, needles and pills. After reaching a weight that is healthier for my body evidence proves that my blood pressure will normalize, thus the use of medication for high blood pressure will be stopped. These are just some of the ways my health will improve after this surgery. I will not expect you to take my word for this and I am including supporting evidence. I am willing to see whatever doctor you choose. I am young and fairly educatated, I say this because I would like you to know that I understand the risks, and what is expected of me to avoid the complications that sometimes occur due to surgical candidates not following Doctors orders. Both of my doctors feel that although I am morbidly obese , I do not fall into the category of Super morbidly obese (BMI of 50 +), which have a higher chance of complications due to surgery. Please give me a chance at a healthy life. I need be an active participant in my family's life. I realize that your job is to provide benefit control for your members so that all may have an equal chance at adequate healthcare. I also know that you do not take this request lightly. This procedure is medically necessary and has not been requested with out consideration for the good of the welfare fund. Dr. Catherine Marino did not say that this was not medically necessary nor that I do not qualify for this procedure she stated that you, the board, are in control of our benefits and that you control the exclusions. Please reconsider this exclusion. Please approve gastric bypass surgery for me. My current doctors which are Magnacare providers. Dr. Sarath Babu 732-249-3100 Dr. Earl Noyan (609) 585-2447 Thank you Madeline Mojica Ps. Supporting literature will be forwarded to [email protected]

Did they ever approved it?