My Appeal Letter to UCH

I am taking this with me to my meeting with my attorney on Monday afternoon. I decided to post this here in case it might help anyone else. Lock and load and let's roll!! Robin United Healthcare Appeals P.O. Box 659773 San Antonio, Texas 78266-9773 Dear United Healthcare: This letter is my personal response to your denial letter of 8/12/03, concerning my need for gastric bypass surgery. (copy attached) I understand that this procedure is listed under "General Exclusions," sub-heading G, page 27 of our group benefits package. The exclusion is for medical or surgical treatment of obesity, including severe or morbid obesity. As a personal note, I find this exclusion to be discriminatory and illogical when looking at costs for the surgery versus costs for treatment of the co-morbidities involved. Because my health is in serious decline, I was referred to Dr. Todd Overcash, by my PCP (his letter is attached), for the surgery. Many attempts to lose weight, only to regain more, have hampered my ability to fight these life-threatening and life-restricting conditions. My BMI (body mass index) combined with the diseases from which I suffer give me an estimated 190% increased risk of early mortality. My health problems are as follows; Type II diabetes, GERD, Severe Obstructive Sleep Apnea (80+ episodes per hour, with 50% loss of oxygen saturation), hypertension and degenerative osteoarthritis in all my weight-bearing joints. So far, my heart is sound but, with diabetes, that can change quickly. My father died of congestive heart failure due to complications of diabetes. He was not an old man. My one other concern is the fact that I was born with a congenital defect of my left kidney, which necessitated its removal due to chronic infections back in the early 70's. I have one operating kidney, and should it fail due to the diabetes, there would certainly be costs for dialysis, possible transplant and all the accompanying drug therapies, etc. As you can see, the probability of expanded claims for these conditions will far outweigh the cost of the surgery that could help me save my life. If the bottom line is the main concern of United Healthcare and Trammel Crow Residential, this should definitely be a valid concern for you. With my BMI of 49, and my family history, there will definitely be large expenditures that ARE covered by this policy in the near future. If I am not mistaken, kidney transplants and heart surgery far out-price the gastric bypass surgery. Joint replacements are also very pricey. What costs would you rather cover, the surgery now, or the more costly treatments and surgery later? If you will pardon the use of an analogy, you cover treatment for blocked arteries. The same factors that cause the blocked arteries also cause obesity and related diseases. The reasoning on this truly escapes me. Drug therapy, which you also do not cover, was not effective for me. I couldn't afford it, and the "Fen-Phen" became a health concern and Meridia was just too expensive for us on our limited income. The Meridia, which I did take for about 5 months, stopped working after 3 months and, at over $100 per month, the cost was prohibitive. I have been on the ADA (American Diabetic Association) food plan since June of 2002 and it has ceased to be effective. I lost 40 lbs (from 300# to 260#) and have gained it all back plus some. I have been an in-patient of the Rader Institute, which uses behavior modification. It worked for about a year or so and then the demands of my body started fighting back. I have used the Atkins diet, Optifast, Slim-Fast, Weigh****chers, etc., ad infinitum, ad nauseum. The "yo-yo" effect was even more harmful to my health. Americans spend an estimated $33 billion, annually, on weight-reduction products and programs and services. Most of these expenditures, as evidenced in my case, are not effective. Kaiser Permanente Medical Care Program subjects, numbering 17,118, were studied to determine the association between obesity and health care costs. The results were published March 9, 1998, showing an increased inpatient and outpatients cost ration of 2.4 percent greater. The quality of my life has also suffered. I can't even take walks with my family. On vacations, I sit in a beach chair while the rest of the family walks the beach or the shops, etc, enjoying themselves without me. My health problems are also affecting my work, a job with some real responsibility that I am hanging onto with sheer determination, right now. I am too tired, most of the time, to do any of the things I truly enjoy. I also suffer from a pronounced rectocele, which is causing me lower bowel problems and interfering with my marriage. This condition cannot be corrected as long as I remain overweight The option of self-paying for this surgery is out of the question. We would not qualify for a loan and we have large house and car payments. While we both are working, we are among the lower-middle income bracket that has to put everything they make into living expenses, paycheck to paycheck. I truly don't care how I look as far as my size is concerned. I think that beauty comes in all sizes and shapes and ages and colors. BUT, I do care whether I live or die and, to improve my health and prolong my life, I need this surgery. When the weight comes off, you will already be saving the expenditures per month and year that you already pay for Rx and testing supplies, CPAP rental and replacement masks, repeated lab work and office visits and hospitalizations, not to mention the probable future costs mentioned previously. My condition is not a "lifestyle choice" or a matter of laziness or gluttony. I have fought this battle for so long now that I am exhausted and this is my final stand. The forces are gathering to fight this stereotyping of and discrimination against the people who suffer from the disease of obesity. The medical community and, now, the scientific community are recognizing obesity as a disease within itself, as well as a causative factor in other, very serious diseases. It is for these reasons and an acute desire to live, that I am asking you to make my case an exception to the exclusion in our group policy. It means improved health for me, and a logical and meaningful cost savings for you. Sincerely, Robin K. Westbrook Cc: Ed Gay, Atty. Ccc: Dr. W. Todd Overcash, Dr. Michael Bougoulias, Trammel Crow Residential HR Dept. 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. 6. AMOS at obesityhelp.com. You will find articles from the latest studies that show how the body fights weigh loss.

Excellent work, Robin!! As an English instructor, I must say that you write one heck of a persuasive letter!! Hope it gets you what we all deserve.Hugs, Cindy

Hi Robin, Please let us know how your appeal goes. The letter makes a lot of sense to me. Thanks, Tamara