appeal letter advise

I tried to kind of mimic the appeal letters that I have seen but I would like to get opinions on if it sounds ok. The middle part of it is the clinical policy description of what Aetna requires. Please give me any advise in changes. Thank you ! Renee November 1, 2004 Dear Medical Resolution Team: I am writing this letter to formally appeal your decision to deny bariatric weight loss surgery as communicated to me in a letter from >>>>XXXXXXX dated XXXXXXXXXx , 2004. Below you will find, copied in, clinical policy number 157, which states Aetna's requirements for approval of this surgery. Roux-en-Y Gastric Bypass (RYGB): Aetna considers open or laparoscopic Roux-en-Y gastric bypass (RYGB) medically necessary when the selection criteria listed below are met. Selection criteria: 1. Presence of severe obesity that has persisted for at least 5 years, defined as either: a. Body mass index (BMI)* exceeding 40; or b. BMI* greater than 35 in conjunction with any of the following co-morbidities: i. coronary heart disease; or ii. type 2 diabetes mellitus; or iii. clinically significant obstructive sleep apnea (i.e., patient meets the criteria for treatment of obstructive sleep apnea set forth in Aetna CPB 004 - Obstructive Sleep Apnea: Diagnosis and Treatment); or iv. medically refractory hypertension (blood pressure > 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management); and 2. Patient has completed growth (18 years of age or documentation of completion of bone growth); and 3. Member has attempted weight loss in the past without successful long-term weight reduction; and 4. Member must meet either criterion a (physician-supervised nutrition and exercise program) or criterion b (multidisciplinary surgical preparatory regimen): a. Physician-supervised nutrition and exercise program: Member has participated in a physician-supervised nutrition and exercise program (including dietician consultation, low calorie diet, increased physical activity, and behavioral modification), documented in the medical record. This physician-supervised nutrition and exercise program must meet all of the following criteria: i. Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; and ii. Nutrition and exercise program(s) must be for a cumulative total of 6 months or longer in duration, with participation in one program of at least three consecutive months, prior to the date of surgery. (Precertification may be made prior to completion of nutrition and exercise program as long as a cumulative of six months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.); and iii. Nutrition and exercise program must occur within the two years prior to surgery; and iv. Member's participation in a physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who supervised the member's participation. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician. Note: A physician's summary letter is not sufficient documentation. Documentation should include medical records of physician's contemporaneous assessment of patient's progress throughout the course of the nutrition and exercise program. For members who participate in a physician-administered nutrition and exercise program (e.g., MediFast, OptiFast), program records documenting the member's participation and progress may substitute for physician medical records; or b. Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery, member must participate in an organized multidisciplinary surgical preparatory regimen of at least three months duration meeting all of the following criteria, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions: i. Consulation with a dietician or nutritionist; and ii. Reduced-calorie diet program supervised by dietician or nutritionist; and iii. Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and iv. Behavior modification program supervised by qualified professional; and Documentation in the medical record of the member's participation in the multidisciplinary surgical preparatory regimen. (A physician's summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician's initial assessment the member, and an assessment of the member's progress at the completion of the multidisciplinary surgical preparatory regimen.) As stated above there are two options, A) Physician-supervised nutrition and exercise program - or B) Multidisciplinary surgical preparatory regimen In March of 2004 I started option (A) by meeting with my Physician, Dr Michelle Rejman-Peterson out of the Aurora Sheboygan Clinic, Sheboygan Falls Branch. Dr Michelle would take my weight once a month and talk to me about how I was doing with the work outs and my eating. We also had discussed me quitting smoking because of this being major surgery. (As of now I am smoke free for 4 months as of November 11th) Later in the month found out about option (B) which I decided would work better for me instead. I continued to see my Physician until July when my 3 month Multidisciplinary Surgical Preparatory Regimen was completed. On April 19th I started seeing a Dietician through Aurora Memorial Medical Center in Sheboygan under the direction of Linda ????? Her notes are attached. I saw her every week for a month then every other week for the balance of the 3 months. She recorded my weight, we talked about the proper ways of eating healthy with smaller portions. Each time I met with her I paid $14.00 for her services. On April 19th I also started with a physical trainer at the YMCA in Sheboygan Falls under the direction of Emma ???? I have attached the notes and workout times. I started a program with Emma in weight training. We started with a 5 minute warm up which varied from step aerobics to basketball. From there we went into the gym and did 20 minute cardio and 40 minute weight training. Emma was there to show me how to do the weights, how fast or slow, position of seat, hands etc. She determined what was the correct weight that I should lift each time I met with her. I met with Emma 2-3 times a week, the program cost was $50.00. Before I had finished the program I decided to join the Y on a regular basis so that I could come in more often then just during our Class/Program time. What was requested for the Multidisciplinary Surgical Preparatory Regimen was completed. I am now being denied because XXXXX_-----------------------REASON----------------------------_XXXXXXXXXX and I am requested to do the Physician-supervised nutrition and exercise program for 6 months. My surgeon, Dr XXXXXX, his nursing staff, and myself are confused because I have done and submitted all the work and notes requested for the 3 month Multidisciplinary surgical preparatory regimen and yet I am still being denied. I have been assesed with sleep apnea in 1996 ( paperwork is attached) I have slowly been having increasing problems with my knees, which my doctor says it is because of my weight I have a hard time breathing just walking upstairs (even still after quiting smoking) I leak urine if I cough or sneeze I am always tired never have any energy unless I take caffiene I have been on and tried every diet under the sun, to which I have lost weight on some but I always gain it back I have 4 generations of heart disease on my fathers side (all were over weight) I am 6 ft tall at 330. Since I quit smoking I have gained weight but I have been on a plateau and have not gained any in the last month. My BMI is now 45 and before I gained the weight I was at a BMI of 42. I have joined up with my TOPS group again for the support in losing weight with or without this surgery. I am still exercising 3 times a week. I have included a copy of the denial letter that my surgeons office received. Thank you for taking the time to review my information.

Stress your BMI, and your co-morbitities. Throw in your family history and list clearly your failed diet attempts. Then put how you satisfy their criteria but also meet the NIH Criteria. The NIH Criteria is that the Surgery is a LAST RESORT. Your BMI is over 35 with one co-morb or over 40 with none. That's it. The NIH never prescribed a certain lenght of diet time etc. Good luck Gary www.obesitylawyers.com

Renee, I am curious as to why you didn't include the first reason for your denial. "I am now being denied because XXXXX_-----------------------REASON----------------------------_XXXXXXXXXX and I am requested to do the Physician-supervised nutrition and exercise program for 6 months." I might be missing something here... Is there another reason for the denial? You can email me privately in you wish, but I can't give you the answers you need without the whole story. Fight the good fight! Roberta