My second insurance appeal - any suggestions?

I am posting this here because my friend indicated to me that the letter is available on her blog at http://thediaryofafatwoman.blogspot.com.  This was her response to my request for help, “My appeal letters are on my blog…I put them out there because I know I had a semi difficult time finding templates and information I was looking for. If I can help just one person, then I have succeeded. No one should have to be denied a life saving surgery. Best of luck to your friend."  I encourage everyone to check out her blog; her honesty is awe-inspiring.  Here's the letter she wrote after her second denial:

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To Whom It May Concern:

This letter comes in response to my recent denial dated November 21, 2008 for Weight Loss Surgery (WLS). I am writing this letter to implore that you reverse the decision not to approve Vertical Sleeve Gastrectomy (VSG) surgery on the basis it is considered investigational, therefore not medically necessary. In this letter I will explain why VSG is the best surgery for me and dispute BCBSNC’s assessment that VSG is investigational by asking you to review my Level 1 Appeal packet documentation as well as offering additional facts to dispute this claim. I am confident that you will reverse denial upon reviewing this additional information.

It has been established that WLS is medically necessary per my doctors, surgeon and BCBSNC’s medical policy (Attached in Level 1 Appeal packet) and I am grateful WLS is an option for me. I am even more appreciative of the fact that there is more than one WLS to choose from to accommodate a person’s medical and psychological needs. I have spent years researching different types of WLS; the side effects, lifestyle changes, the risks, the pros and the cons. I have read story after story of Gastric Bypass (RNY) and Lap Band being the perfect surgery for one individual, but not the next. I have read how one person’s body adapts to the changes from RNY or Lap band and the next person is continually sick from throwing up, dehydration, diarrhea, malnutrition, band slippage, band erosion; as well as suffering embarrassing moments in public by an abrupt exit because they ate too fast or ate the wrong food and had to make it to a restroom quick.
This is one of the many reasons I feel VSG is the best option for me and my lifestyle. It is the one WLS available that offers the most normalcy post op. There is no re-routing of my intestines so there is less malnutrition risk and complications; the stomach stays intact, it remains a fully functioning stomach so there is minimum chance of dumping and complications. If you take a look at the attached surgery comparison chart you will see that VSG is the optimum choice. I do realize it is still a tool and as with all other WLS, I have to do my part in order to succeed. As I stated in my initial appeal letter, I am a morbidly obese female weighing 379 lbs with a BMI of 61 with mostly obese related co-morbidities that will improve or go away completely with weight loss. This surgery will open the door for a new life for me. I will no longer feel like a kid being punished sitting at their bedroom window watching the other kids play outside.

Partial Gastrectomies have been done on patients suffering from stomach cancer and peptic ulcers for well over 100 years so we know a patient can live successfully with part of the stomach removed. The first gastrectomy was performed by Theodor Billroth in 1881 on a patient with antral carcinoma. The procedure itself has been of course modified and improved over the years just as the original Vertical Gastroplasty of the 1970’s and 1980’s has made the pathway for the significantly improved Vertical Sleeve Gastrectomy. VSG was first performed in 1993 by Dr. Jamieson in England and has since been refined and improved into the VSG we know today by Dr. Gagner in 2001. The VSG has been performed for 15 years and as we know it today for the last 7 years. This is a far cry from an investigational surgery. The results from the studies submitted in my initial appeal packet speak for themselves as well as the people I correspond with on a daily basis on Obesityhelp.com forum ( http://www.obesityhelp.com/forums/vsg/ ) that are real life examples of the success of the VSG with weight loss in excess of 100 lbs with no major complications post op. Laparoscopic Associates of San Francisco has a two year study that can be viewed at www.facs.org/education/gs2004/gs33lee.pdf as a slideshow. I am confident the information provided is significant enough to disprove VSG as an investigational surgery. More insurance companies including BCBS Carefirst and Federal BCBS are adapting VSG in with their policies; this is further clarification this surgery is no longer considered investigational.

Please take a closer look at my initial Appeal Packet as well as the additional documentation attached. I am excited to begin a new life with the surgery that will most benefit me. I look forward to hearing from you soon with good news of a reversal of the initial denial. Thank you for your time.

Sincerely,

Research links:
http://www.obesityhelp.com/forums/vsg/cmsID,8874/mode,content/a,cms/
http://www.lapsf.com/vertical-gastrectomy-weight-loss-surgery.php

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Following this letter which was submitted in early Dec 2008, an external review board approved her surgery, she was notified of the decision on 01/07/2009 and had surgery on 01/22/2009.

It can be done...but you have to be your own best advocate!  By the way, her second link to Laparoscopic Surgery Associates of San Francisco, arguably one of the best bariatric programs worldwide, provides a bevy of information and studies on all surgery types.  I usually suggest that people start their research with the comparison chart located at http://www.lapsf.com/weight-loss-surgeries.html.

Best wishes and positive thoughts being sent to you as you walk the path towards a happier, healthier, and longer life!

~Namaste~

Amy

Ps:  Her first appeal letter can be found at her blog on the entry for 11/10/2008.