Approved for Revision

Hi Kim can you email me the information you have in a appeal letter.I have bcbs of texas. I sent you a message. my email is [email protected]. thnk you so much appreciate all your help.

 i have BCBS and mine would be covered as well.  maybe every employer has different stipulations set up, ya know?

 Congrats!!  I hope everything goes great with your surgery! 

Thank you!

 Just curious, why were they initially denying you?

I think that I have filled out the wrong form I am seeing Dr. B on Tuesday, but Im not sure how it will go, I haven.t been denied . I do have2 ins. carriers so I'm praying that it will be a go, I just recently last 2-3 yrs. started to regain my weight, so for at least 8-9 yrs. I have keep my wt. down, but I cant seem to loose any of this wt. I have regained. I spent about 2 grand with Nutri- system wt. comes off but does not stay that way, Im so sad about my fat behind now! boo hoo.. hope that Dr. B will agree to this revision...
 

BCBS said that I was non compliant with post surgical deitary and exercise requirements.  They also stated that there should be at least 2 years beween surgeries and and it has only been 17 months at the time. I provided them with a exercise log and food journal to prove otherwise. 

Here is my appeal letter. I strongly suggest that you include losts of scientificstudies to support your need for a revision based on your co-morbidities.  Please feel free to use or modify as needed.  Good luck and best wishes.

Dear Sir or Madam:

On December 7, 2011, I received a claim denial for the above referenced claim based on the following reasons:

· Previous surgery for morbid obesity was not 2 years prior to repeat procedure

· Member did not provide documentation of compliance with previously prescribed post-operative exercise program

I am appealing this decision and request full reconsideration.

Background

I am a 42 year old African American female and have been overweight since I was about 4 years-old. My height is 5 feet 7 inches, I currently weigh 286 pounds and my BMI is 45. I originally had weight loss surgery on July 7, 2010 at Northside Hospital in Atlanta, Georgia. I selected the Realize Band because it was minimally invasive and advertised that I would lose 50% per my excess weight.

 

Complications

Despite following all post-operative guidelines, the Realize Band is ineffective and I have suffered from the following complications and adverse side effects:

· Esophageal dilatation

· Duodenitis

· Constant nausea and vomiting

· Abdominal pain

· Inability to maintain proper restriction

 

Clinical Research

Many studies show that Gastric Banding has higher failure rates when compared to other weigh loss surgeries, particularly for African Americans. The study in particular, “High Failure Rates After Laparoscopic Adjustable Silicone Gastric Banding for Treatment of Morbid Obesity" did not find Gastric banding to be an effective procedure for the surgical treatment of morbid obesity, particularly in African American patients.

Likewise, Dr. M. Suter authored “A 10-year Experience with Laparoscopic Gastric Banding for Morbid Obesity: High Long-Term Complication and Failure Rates". He concludes that Laparoscopic Gastric Banding should no longer be considered as the procedure of choice for obesity.

Dr. H.G. Weiss authored “Surgical revision after failure of laparoscopic adjustable

gastric banding". Dr. Weiss concludes that Adjustable Gastric Banding placement is associated with a variety of complications. In most cases surgical complications can be treated with minimally invasive surgery, which should allow further weight loss and improvement of quality of life during long-term follow-up. Alternative bariatric procedures should be reserved for patients with poor outcome after surgical revision of the Adjustable Gastric Band.

Copies of the aforementioned studies have been provided for your review.

Eligibility Criteria

Your eligibility criteria states that subsequent morbid obesity surgery must be at least two years prior to the repeat procedure, however, my complications and side effects have been very persistent over the past year and half and it is highly unlikely that they will subside or disappear in the next 7 months. My need to have subsequent surgery for morbid obesity is an attempt to access immediate treatment and care.

 

Exercise

I fully understand that exercise is critical to achieving and sustaining weight loss. I have complied with the prescribed post-operative exercise program. From August 2010 to February 2011, I hired personal trainer, Dean Said. During this time, I worked out my trainer approximately 2 times per week for 45 minutes per session. In addition to my workout sessions, I also walked a minimum of 10 minutes a day approximately twice a week. Unfortunately, my finances would not allow me to continue the services of my trainer but I continued to work out on my own and walk regularly. I was hoping that the Realize Band would alleviate my health conditions and improve my mobility however; my current weight, arthritis and joint pain interfere with my ability to exercise regularly. I have included fitness log for your review as documentation of my efforts.

 

Being Morbid Obese

I have been on diets my whole life, having some success, but would always gain the weight back I lost, plus more. The following is a list of additional weight loss methods that I’ve tried over the years:

· Weigh****chers

· Nutri–Systems

· Jenny Craig

· Atkins

· Medically supervised diet and shots

· South Beach diet

· Cabbage soup diet

· Redux pills, under a medical doctor’s care

· Overeaters Anonymous

· Slim Fast

· Xenical

· Gym

· Protein Power Book Diet

As you can see I have exhausted all the traditional ways to lose weight and the Realize Band has also been ineffective for several reasons but not due to my lack of effort, commitment or compliance. Additionally, I still have many co-morbid diseases, such as high blood pressure, arthritis and pains in my joints. I am on HCTZ and Benazepril. Weight loss surgery will sever my otherwise lifelong dependency on these medications.

 

Being morbidly obese puts a strain on everything I do. I cannot walk very far without getting out of breath, I cannot tie my shoes, fit in small seats whether in airplanes, an office waiting room, theater, ball park or restaurant, wherever they may be. I am embarrassed of what I look like. I lack self-confidence. I am not functioning to my full potential at work. I am always exhausted to the point of falling asleep at my desk. It takes me twice as long to do many things. I have no energy. I can’t eat in public because the band causes food to constantly get stuck and I throw up. I want to be more active and able to do the things normal sized people do. I do not want to die. The gastric bypass is an approved and proven means to permanently lose weight. I know this surgery will be a life saver for me. Please reconsider your decision and approve this surgery for me and save my life.