First Appeal Letter, by popular request

Please note, at the end of this letter I also added my own weight lost spread sheet. Leave nothing to chance. Good Luck, and please feel free to use. A lot of time and research went into both of my letters. It is my belief that many exclusions are not well written, and are open to interpretation. Does your's say "for obesity" and not morbid obesity? Point that out in your letter (see my second appeal letter that is posted). Be sure to go to the NIH website and print the consensus statement and include it with your letter. Send as much supporting documentation you can find, it is all here on the web. Good Luck to all. /United Health Care Re: Exclusion of Gastric Bypass Surgery for Diagnosis of Morbid Obesity. To Whom It May Concern: This letter is to appeal your insurance exclusion for RNY gastric bypass surgery (Diagnosis Code 278.01 Procedure Code 43846). I was referred for this surgery by my PCP, who is very concerned about my health because of severe morbid obesity. I am a 48 year old severely morbidly obese female who is 5'7'' tall and weigh 262 lbs., giving me a body mass index of 41. The body mass index ("BMI") 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 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 was diagnosed on June 4, 2004 with tricuspid regurgitation (heart valve leakage). My LV ejection fraction is about 68% which is exacerbated by severe morbid obesity, and is more likely to cause congestive heart failure. I have on two separate occasions broken my right foot (4th & 5th metatarsals) losing my balance with the weight crushing the bones, once in 1995 and the second time in 2001. I am having significant adverse symptoms from my 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 in 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 along with chronic bronchitis aggravated by my weight. 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 I take medication daily. I have pains and aches in my back, and legs, I am now experiencing moderate to severe pain in my hips. I have difficulty sleeping, and therefore am fatigued and tired during the day. This surgery usually cures acid reflux and sleep disturbances. I have made many, many attempts to lose weight and this has gone on all my life (see attached chart). I was put on medications by my doctor to help me 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 tried Nutri-System. A doctor specializing in Woman's Health issues prescribed Phen-Fen/redux for over two years resulting in minor weight loss, and then regaining the weight as soon as the medication was stopped. 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 to say nothing of being at risk for SDD (sudden death syndrome). I have also tried many exercise programs without success. 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 Permanente 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 he will continue to gain weight and the costs of co-morbid conditions, including the ones he already has and ones he surely will acquire as time goes on, will far outweigh the costs of gastric bypass surgery. My father died at age 62 from a diabetic related stroke and my mother at age 60 of cancer, all of which I stand to inherit and repeat with out immediate attention. As you can see I have exhausted all the traditional ways to lose weight. Gastric Bypass surgery has been deemed an immediate medical necessity. The gastric bypass is an approved and proven means to permanently lose weight and reduce mortality in sever morbid obesity. Gastric Bypass is not considered educational or experimental (Friedman-Knowles Experimental Treatment Act of 1996) and I do meet the qualifications of "Medically Necessary" as outlined in the employee benefits guide and the Friedman-Knowles Experimental Treatment Act of 1996 (Section 1370.4 & 1370 (a) (1) (2) (3) (d) (4) pursuant to paragraph (3)). In your exclusions, it states not covered for "Treatments for loss, maintenance or increase of body weight (including, but not limited to, operations such as obesity surgery or gastric bypass)" but does not lay out any exclusions specifically for severe morbid obesity. Please approve this surgery for me. Thank you. Nothing herein is a waiver of any of my rights, at law or in equity, all of which are hereby expressly reserved. Sincerely, Viola H. Collins Enclosures CO-MORBIDITIES (1) As of April 27, 2004 a weight of 262.7 lbs., 5'7''. (2) Diagnosed November 2003 with GERD requiring daily medication coupled with increased incidents of Prolapsed Mitro Valve heart palpitations. Dr. Steven Witlin (3) June 1995: Fracture of 5th metatarsal of left foot caused from weight crushing my foot while walking. Dr. Robert Heller, Culver City Medical Group, Culver City, California. (4) June 1997: Fracture of the right forearm caused from the weight in breaking a fall while walking. Daniel Freeman Marina Hospital, Marina del Rey, California. (5) July 2001: Break of the 4th and 5th metatarsal of the right foot caused from weight crushing my foot. Dr. Slay, Daniel Freeman Marina Hospital, Marina del Rey, California and Dr. Jason Harvey, UCLA Harbor Medical Center, Carson, California. (6) July 2002: Sprain of right thumb after breaking a fall while walking. Mid-City Hospital Los Angeles, California (emergency room treating physician). (7) Mother died 1994 age 60 of Cancer. (8) Father died 1995 age 62 of Heart Attack/Stroke/Diabetes. (9) June 4, 2004: Diagnosed with tricuspid valve regurgitation. (10) Chronic bronchitis. REFERENCES Weighing the Options: Criteria for Evaluating Weight-Management Programs. Institute of Medicine, National Academy of Sciences, 1995, pp. 50-51. 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. 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. 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. Weight control: What works and why. Medical Essay. Mayo Foundation for Medical Education and Research, 1994.

Viola, Good luck on your appeal. I also have UHC coverage, and reconstructive surgery is totally excluded. However, I did get my WLS paid for. Let me caution you and everyone else that when an insurance company sees the same basic letter, they just skip over, and don't bother reading it. I have seen parts of your letter, many times on other sites. Appeals should speak directly to the provision(s) that the denial is based on. Everything else is unimportant. Fight the good fight! Roberta

Hi Roberta, thanks for your imput, as I am dealing with the VP of benefits of our company (we are self funded) I am not as concerned that many of our letters sound a like. I am not sure how many people have bothered to appeal the exclusion in our policy. UHC is only our admistrator. I would be interested in knowing if your company was self funded, and if they had an exclusion. This letter speaks directly to the denial letter in which they thought it was experimental, not a proven method, and statistics. In my second appeal I address the difference between obesity and morbid obesity. All insight is welcomed.

Viola, Well I found the letters you refered to on the main message board. Thanks again. I also want to mention that my plan is a self-funded plan. At this time I have received my first denial, they claim I did not meet my burden of proof. But I cannot even get my plan administrator to tell me what else they need. I'm just supposed to keep appealling & they will keep denying I guess. Irene

Irene, In your benefits package they will lay out step by step the appeal process. a self funded plan does not necessarily have to submit to the ERISA process. Does your exclusion say specifically for MORBID obesity? It sounds like you may just need to do some additional paper work and bombard them with medical necessity and history of co-morbidities. There is a lot or research referred to in my letters. Go to the NIH consensus down load it and use it. Here are a few links. http://www.niddk.nih.gov/health/nutrit/pubs/gastric/gastricsurgery.htm http://odp.od.nih.gov/consensus/cons/084/084_statement.htm http://www.obesity.org/subs/fastfacts/obesity_women.shtml