Benefits Appeal Committee

I'm am appealing my companies decision to exclude WLS. I have to write a letter to the committee and I want some ideas of what I should include. Here is what I have so far. What do you think? February 15, 2005 Benefit Appeals Committee To Whom It May Concern: I am requesting to have the Weight Loss Surgery exclusion overridden. I have done a lot of research into this procedure over the past year in preparation. I have attended two seminars with surgeons in the Tampa Bay area. The Wish Center and Dr. Murr at Tampa General Hospital. I have done research on-line at Obesityhelp.com. During open enrollment last year I checked with the representative of United Health Care so see if weight loss surgery was covered under the new policy and was told yes. So based on that information I choice United Health Care Choice plan. When I received my card in the mail I called the customer service number on the back and spoke with Jennifer in Customer Service and asked her if weight loss surgery was covered she told me yes at 100% if medically necessary. I proceeded to attend another seminar/ orientation at Town and Country Hospital for the Wish Center and made an appointment for January 17, 2005. Between the 3rd and the 17th of January I called again to check and make sure that the Wish Center and Dr Dietrick were in network and was told that they were. Upon attending my appointment I was informed half way through that Trish at the Wish Center had called UHC to check coverage and she was told it wasn't covered. I myself called while in the office to check and was told then that it wasn't covered and I was given the wrong information earlier in the month. I left the office very upset without completing the requirements set forth by the Wish Center. I got home and called customer service to see why I was given the wrong information and was told that they had only recently been told that it wasn't a covered expense. I am 45 years old with 5 children and I have always been over weight. I have been on numerous diets through out my life. I have lost an average of 20 lbs. per diet attempt only to gain it back and then some. Weigh****chers- 3-4 times Eat Right for your blood type 2-3 times Adkins- 3-4 times South Beach Diet Body for Life Richard Simmons- deal a meal Numerous exercise videos My current co-morbidity's are as follows: Weight- 325 lbs. With a BMI of 50 High cholesterol Osteoarthritis in my knees and neck. Pain in my lower back Herniated disc in my neck. Urinary incontinence Irregular menstrual cycles Rashes in the folds of my skin. I am borderline diabetic. My blood pressure fluctuates between high and normal. Hypothyroid Swelling in my feet and legs Carprel Tunnel - Moderate Current medications: Prescription Rx's Levoxyl 200mcg 1 daily Ibuprofen 800 mg 2 daily Over the Counter medication: Lotrimin AF- recommended by Dr Viera for the skin rashes B-complex recommended by Dr Pedragal for carprel tunnel During open enrollment last year I checked with the representative who was passing out The brochure here at work from United Health Care to see if weight loss surgery was covered under the new policy and was told yes. So based on that information I chose United Health Care Choice plan. When I received my card in the mail I called the customer service number on the back and spoke with Jennifer in Customer Service and asked her if weight loss surgery was covered she told me yes at 100% if medically necessary. I proceeded to attend another seminar/ orientation at Town and Country Hospital for the Wish Center and made an appointment for January 17, 2005. Between the 3rd and the 17th of January I called again to check and make sure that the Wish Center and Dr Dietrick were in network and was told that they were. Upon attending my appointment I was informed half way through that Trish at the Wish Center had called UHC to check coverage and she was told it wasn't covered. I myself called while in the office to check and was told by Patricia that it wasn't covered and I was given the wrong information earlier in the month. I left the office very upset without completing the requirements set forth by the Wish Center. When I returned home and had calmed down. I called customer service again to see why I was given the wrong information . I was told by Christina that they had only recently been informed that WLS was not a covered procedure. I am afraid if I'm not able to have this surgery that my co-morbidities will just continue to develop. And my future doesn't look to good from where I'm sitting. The list of things I could suffer from and some I already have are... Heart disease (Hypertension, stroke, Coronary Artery disease)...and mind you heart bypass surgery is much more expensive than gastric bypass. Respiratory problems (obstructive sleep apnea, shortness of breat) these I may already have but haven't been diagnosed as of yet. Circulatory problems (peripheral vascular disease, edema) Bone and joint disorders ( arthritis, disk problems in the knees, neck, back...sometimes requiring surgery) ***already have Nerve problems (neuropathy) Hormonal problems (irregular menstral cycles and polcystic ovarian syndrome...which is worse with obesity) Mental anguish, from the discrimination against obesity, and the effects being obese does on your self esteem and confidence. Diabetes I have included some letter from co-workers that have had the surgery and how it has affected their health and life on a whole. Even though I know there are risks involved in this surgery I think in the long run that I would be able to live a healthy life if I am allowed to have it. Some of the top 10 things I look forward to being able to do after surgery.... Go one day without pain. Be able to tie my shoes in the middle. Cross my legs. Fit in a movie theatre seat without forcing myself into it. Be able to walk from my desk at work to the break room and not be out of breath. Be able to pick a restaurant without thinking if I'll fit in the booth or not. Not have to turn sideways to fit through a turn style and sometimes get stuck. Be able to ride a bike with my kids Be around to play with my grandchildren. Feel better about myself and not feel like everyone is looking at me when I enter a room. I could go on and on and on. There are so many things that I would like to do with what life I have left to live.

Good Job Jennifer! I would like to add that you should probably detail money that you spent and services that were covered by the insurance company (especially visits to the surgeon)...because if the insurance company is spending money to support events leading up to approval, a reasonable person would think it's a covered benefit. Also, decide if you want to make this a covered benefit for everyone in your company or just you. If you want this to be available to others, make some of your complaints more general if that makes sense. Place emphasis on the general benefits of this surgery. Good Luck!

This may be a dumb question and I'm sure you've already looked into this but I was wondering if you've recieved any of this information in writing? Have you taken a look at your Summary Benefits booklet provided by your employer? Does it specifically say that gastric bypass is not covered whether it's medically necessary or not? I'm asking this because I know that the customer service reps are the worst at giving out information. I would look for it in writing just to make sure. Good luck.

If this is an appeal to your employer to remove a WLS exclusion, I would stick with the dollar and cents costs to the company caused by over weight workers -- ex. lost work time, absentism, higher medical costs and so on. (Employers are far more likely to do something if it will save them money!) The information can be found on articles on this site. Face it companies are more concerned with their dollars than our health. The more concise it is, the more likely they will be to actually read it. After you list the costs to companies because of weight problems then have a section called: My co-morbidities: (then list them). You could even throw in the cost of training new workers to replace those that are forced to leave due to their failing health... and maybe costs of disabilities. These are just suggestions that you might want to consider.

Jennifer, The information as to your health etc. is very good, but normally something they ignore. What they care about is dollars and cents. If you can show proof that you began the process during the time it was covered you should say that. Right now, all they care about is the fact that it is excluded. It sounds like this is a self funded plan. If so, you need to speak to your HR Department and explain the situation. There have been times self funded plans have offered privacy agreements where they allow you to have the surgery as long as you told no one it was covered. Speak to them in private about that. Keep pushing on the cost savings to them and put in how long you've been an employee and will continue on etc.. Savings in your medication, doctor visits etc. Maybe they can even negotiate a better fee with the Surgeon and that will be more attractive to them. Other then that, I think you've done a great job. Just don't quit. Gary