Appeal Letter with PCOS

YOUR ADDRESS

DATE

RE: Case XXXXXXX

Dear NAME OF YOUR INSURANCE COMPANY:

This letter will serve as an appeal to the denial of Case #xxxxxxx for Sleeve Gastrectomy. The letter indicated that the denial was because my BMI is less than 40 and I have no severe cardiovascular or other comorbid conditions documented. In the letter, and I quote, “Please refer to the sections of your plan document on limitations and exclusions." A plan summary is only available so I cannot refer to the plan document. Please send me copies of all documents, records and health plan provisions, internal rules guidelines and protocols and any other relevant information that was used to make this determination.

At 37.7 BMI, I am only 2.3 points away from morbid obesity which equates to approximately fifteen pounds. My doctor listed two of my comorbidities as being Code 401.1 Hypertension and Code 272.0 Hypercholesterolemia. I have sent documentation of my Hypercholesterolemia. According to my research, these are comorbidities of obesity.

My medical history is complicated. As a teenage girl, I was diagnosed with Polycystic Ovarian Syndrome. Thus, that diagnosis is at the heart of most of my medical issues.  With PCOS comes obesity, metabolic syndrome, diabetes and infertility.  As of yet, I do not have diabetes. I have tried Metformin to control my insulin resistance but was unable to continue taking it due to its side effects. My mother has had diabetes for over twenty years and is morbidly obese. Both of my sisters suffer from morbid obesity. Research has shown that woman with PCOS have a difficult time losing weight and keeping it off.

After successful fertility treatments, I gave birth to triplets in 1999. I returned to my hormone therapy after weaning them. I was able to keep my weight under control by using hormone therapy such as Loestrin birth control pills. This medication was covered by this insurance plan due to the medical necessity of controlling my hormone levels. Unfortunately in 2005, I suffered a STROKE on my fifth cranial nerve. My doctors refused to allow me to continue taking hormones to control the PCOS. UHC approved my tubal ligation as medically necessary to prevent further pregnancies with the history of the stroke. Thus, the battle of weight control begins.

Over time, I have steadily increased in weight. At times, I have been successful in losing twenty or so pounds, but would gain it back and more within a few months. Just in the last five years, I have seen Dr. XYZ in Spring Texas, followed Metabolic Research plan, and most recently, joined Weigh****chers for over a year only to lose eleven pounds. During that year with Weigh****chers, I walked over three miles every other day.

Currently I am on my third medication to get my Hypercholesterolemia under control without success. Documents have been sent to show my last year’s levels. These tests were conducted while I was on cholesterol reducing medicines. When I am not on these medicines, my levels go into the 300’s. I have used Zocor, Vytorin, Simvastatin and now Lipitor to no avail. I am barely tolerating the Lipitor. My joints have started aching and my cholesterol still remains high. According to Familydoctor.org levels past 240 ml are putting me at into the high risk category for heart disease.

The decision to have this surgery has not been taken lightly. I am aware that weight loss surgery is not a cure, but a tool to assist in weight loss. I understand that it requires a lifelong commitment and that my success or failure will depend on my ability to modify my behavior. I have spoken with people who have had the procedure and read information from various publications and websites, including the American Society for Metabolic and Bariatric Surgery. I have discussed the risks and benefits of weight loss surgery with medical professionals – including my bariatric surgeon and my primary care physician. Based on my history of failure with other weight loss programs, I believe this is surgery will give me the opportunity for a future free of Lipitor and blood pressure medicines.

In Summary:

            Hypertension (Lisinopril)

Hypercholesterolemia (80 mg Lipitor)

            PCOS

            Stroke

All are valid reasons to have this surgery even more in fact because there are four issues.

Sincerely,

xxxxxx

Thank you for sharing, I am concerned about my insurance company not approving my surgery because I have only recently been taking HTN medication.  

I am wondering if it was approved too. Who is your insurance company?