Comments please on my letter to BCBS

To Whom It May Concern: I am writing to appeal the denial of coverage for a revision to my Rouy-en-Y gastric bypass. I had a Rouy-en-Y bypass in April 2003 at the Ohio State University in Columbus, Ohio performed by Dr. Charles Cook. I currently weigh 298lbs with a BMI of 52.7. My BMI places me in the category of being super morbidly obese. As per my policy through ICUBA, the treatment of morbid obesity, including surgical treatment, is a covered benefit and therefore this medically necessary procedure should be covered.

The denial letter dated July 10, 2006 stated the reason for denial as: The patient had a rouy en Y bypass and lost weight successfully but has regained weight.

This statement is incorrect for two reasons:

1. My pre-op weight was 462.

My ideal weight based on my height of 5’3” is 120lbs.

Therefore I originally had 342lbs of excess weight to lose.

My current weight is 298lbs. I have lost a total of 164lbs which is 48% of excess lost.

Therefore, I do not meet the definition of successful post-op weight loss which is between 55-70%.

2. I have not regained weight. The accompanying documentation from my original surgeon’s, Dr. Cook, clinical notes and my current primary care physician’s, Dr. Livingstone, clinical notes will show my continual documented post-op weight from April 2003 until present. 298lbs is the least I have ever weighed.

Final weight with Dr. Cook May 2004: 334lbs.

            First weight with Dr. Livingstone September 2004: 337lbs

            Current weight 298lbs.

Per BCBS medical policy G-24: Repeat or Revised Bariatric Surgical Procedures (43848, 43886-43888)

  Conversion of a gastric restrictive procedure without gastric bypass (e.g., vertical banded gastroplasty) to a gastric restrictive procedure with gastric bypass (e.g., for morbid obesity)            

 Revision of a failed gastric restrictive procedure (e.g., restapling of dehisced vertical banded gastroplasty staple line, severe adhesions of the gastric pouch, stenosis of stoma, dilation of stoma)                                                              

A Roux-en-Y gastric bypass (43644, 43846) may be considered medically necessary for patients who have not had adequate weight loss (defined as loss of more than 50 percent of excess body weight) from vertical banded gastroplasty (43842). Since, maximal weight loss is not typically achieved until 1 to 2 years of vertical banded gastroplasty, a Roux-en-Y gastric bypass is considered not medically necessary and not covered if performed within two years of a vertical banded gastroplasty.  In addition, a Roux-en-Y gastric bypass following vertical banded gastroplasty is considered not medically necessary and not covered for patients who have been substantially noncompliant with a prescribed nutrition and exercise program following the vertical banded gastroplasty. More than one vertical banded gastroplasty or Roux-en-Y gastric bypass procedure is considered not medically necessary.                                                    

  Reoperation may be required to either “take-down” or revise the original bariatric procedure.  Surgical revision or reversal (i.e., take-down) is covered for members who have complications from the primary procedure demonstrated by diagnostic study (e.g., obstruction, stricture, dilation of the gastric pouch).  A reoperation or reversal is considered not medically necessary unless the primary bariatric surgery has resulted in complications, and therefore, it is not covered.                                                

  The accompanying reports from diagnostic tests conducted demonstrate several complications resulting from and associated with the primary Rouy-en-Y gastric bypass surgery.

 Upper Endoscopy: dilated stoma, hiatal hernia Upper GI: gastroesophageal reflux, dilated gastric pouch measuring ?????? Abdominal CT: large ventral hernia measuring 10.0 cm

The gastroesphageal reflux is directly caused from the hiatal hernia and I suffered from neither prior to my Rouy-nY gastric bypass. The large ventral hernia developed within three months post-op along the mid-incision line made for the open Rouy-n-Y gastric bypass. In addition, Dr. Cook’s clinical notes show that I indicated during post-op visits that early satiety was not being experienced. However, since I was compliant with nutrition and exercise and losing at the time Dr. Cook did not explore issue further. I have also included the clinical notes from all post-op visits with dietician at Ohio State to show I was compliant with the recommended post-op eating plan. The dilated stoma and dilated gastric pouch have led to my inability to lose the remainder of my excess weight, thus continuing to leave me Super Morbidly Obese and suffering with co-morbidies related to my excess weight.

  In the past two years, under the care of Dr. Livingstone, I have been treated for four new co-morbidies that I did not suffer with prior to the primary Rouy-n-Y gastric bypass surgery. I now have a recent history of deep vein thrombosis (DVT), transient ischemic attack (TIA), heart palpitations, and osteoarthritis of the knee.  I had all diagnostic and hematological work-up for other possible risk factors for DVT and TIA and at this point the only risk factor that exists is that I am super morbidly obese. Therefore, I am asking that BCBS make a good faith review of my appeal for a revision to my gastric bypass procedure (codes 43848, 43860) based on the medical neccesity of the complications from the original surgery, and in order to treat my co-morbid conditions caused by still being super morbidly obese.

 If you have questions regarding this please contact Dr. Keri Livingstone, Dr. Patricia Byers or me.

  Sincerely, Sarah M.