FINALLY!!! APPROVED!!!! THANK YOU!

Hi all-

Good news, I am finally approved on second appeal.

Like many - I used Nan's letters, stuck to the specific details on what they were asking for and used all available sources to gather info for the appeal.

I hope to have a date later this week.

Thank you all for all of your support!

Maria

Maria!!!!!  Congratulations!!!!!  This is GREAT news!!  I am very happy for you!!

Nan

Can you send me a copy of the letters?  [email protected] 

I am so excited for you!!!  Congratulations and keep us posted when you get your date!!

   letter I used (adapted from nans) I also attached copies of the phyicians notes I referenced etc   RE:      Maria DOB: 10/09   Employer Name:  Employer Acct No: Group Number:               To Whom It May Concern:   I am writing this letter to appeal your decision for denying my medically needed weight loss surgery. My height is 5’4" and my weight is 355 lbs. I have a BMI of 60. As my diet history shows, diet and exercise have helped, but as long term permanent weight loss I feel that weight loss surgery is my only solution. I have researched and learned about weight loss surgery and have worked with my physician and dietician to decide which is the best solution for me. I know there are risks involved with the surgery, but I believe that the risks of being morbidly obese outweigh the risks of surgery.   I am 38 years old and have been overweight since I was about 8 years old. I have been on diets my entire life, having some successes, but would always gain the weight I had lost back, plus more! I will list the diets I have been on throughout my life.   ·                                 Weigh****chers ·                                 Quick Weight Loss ·                                 Physicians Weight Loss ·                                 Diet Center ·                                 Jenny Craig ·                                 Cabbage soup diet ·                                 Mayo Clinic Diet ·                                 Phentermine, under a medical doctor’s care ·                                 Slim Fast ·                                 Bally’s Fitness Center ·                                 Protein Power ·                                 6 Week Body Make-over Diet ·                                 Weigh Down Workshop ·                                 First Place for Health System ·                                 Herbalife Herbal Supplement ·                                 Dexitrim ·                                 Lemonade Cleansing Diet       Currently, I am being monitored by my doctor, being weighed in once a month. I am also seeing a dietician, and working on exercises that I can do with my bad knees such as light yoga and water waling at both The Park Forest Aqua Center and LA Fitness. I began seeing my physician on March 24, 2010 in order to meet the requirements of Aetna’s 6 month physician monitored weight loss program. In addition to my doctor, I saw their in house dietician and am working with a LCSW to address behavior modification issues. I have also joined various local support groups in order to supplement my weight loss journey.   Along with my BMI being 60, I have co-morbid diseases, such as Poly cystic ovarian syndrome (PCOS), sleep apnea, high cholesterol, and pain in my joints, knees and lower legs, GERD as well as lower extremity edema. My family has a history of cancer (mother and father), heart disease (father).  I feel that being morbidly obese puts a strain on everything that I do and also affects my personal hygiene. I cannot walk very far without becoming out of breath. I have a hard time walking up and down stairs because I am out of breath and it hurts my knees. I have a hard time putting on my socks and shoes. I feel I can not live a normal life because I have a hard time fitting in small seats such as on an airplane, in a movie theater, at the ball park, or in a restaurant. I am embarrassed of what I look like, but more importantly, I fear for my health. I want to be around for my family and I feel that my weight is hurting my health. I lack self confidence and feel I am not functioning to my full potential. I want to be more active and be able to do the things normal sized people do.   If you look at my paperwork submitted, you will see that I have met the requirements for qualifying for weight loss surgery as spelled out in the Clinical Policy Bulletin 0157.  *I have had the presence of severe obesity that has persisted for at least the last 8 years *I am over the age of 18, and I have attempted many, many weight loss regimens in the past without long term success *I have a BMI of 60, along with co-morbidities *Lastly, I have completed the process of the 6 month physician supervised weight loss program.  I did this by visiting my physician, visiting the dietician, seeing an LCSW for behavior modification , all which has been documented in the following paperwork. The duration of this program was a full six months, actually 187 days, or 26 weeks, 5 days.   I know this surgery will be a life saver for me. Please reconsider your decision, as I have met the requirements that you have asked for.   Thank you and I look forward to hearing from you soon.   Sincerely,

    Selection criteria compliance – Maria  Member Number    Selection Criteria as Outlined in Clinical Policy Bulletin Obesity Surgery Number 0157   A.  

1. I am an adult, age 38, born 10-

  I have severe obesity. See weight charted in medical record at 343 in 2008, 341 in 2009 and 361.3 in 2010 (records attached)   I have a BMI of 60, with co-morbidities     B.  

1. I have completed a 6 month nutritionist supervised, physician supervised weight loss program from 3-24-2010 to 9-27-2010, for a duration of 26 weeks, 5 days, or 187 days. I have lost 6 pounds on this program, stopped drinking soda, reduced caffeine consumption by 75%, learned to exercise in short increments to avoid aggravating my joints and edema. Proofs of these visits, signed by my physician, Dr. Omar Shamsi, are attached, along with the assessment of the nutritionist who works in conjunction with the program.

  I have also worked with an Aetna Network Licensed Clinical Social Worker (LCSW) to address behavioral changes needed both now and after surgery. Notes also attached.       Please reconsider your decision to deny my surgery, as I have clearly met the requirements of Clinical Policy Bulletin 0157. also sent this