The other side of the coin

Considering that the costs of health care, due to co-morbidities of obesity, far out-weigh the cost of WL surgery, *I* believe that your are missing the boat on this one.   You have the chance to help pay forward the opportunities that you have been afforded, yet you are choosing to side with 'the company' to save a few extra bucks in the SHORT RUN.

I am not choosing anything. I am forced to sit back and allow the choice to be made. There are other sides to situations such as this. I have never been on this side. There is alot to consider. I get paid to look out for my companies best interest. The problem is there are no hard stats supporting your assumptions that my company shelling out potentially hundreds of thousands of dollars will benefit them somewhere down the road. If I could prove that would happen, I would certainly present it.

Either your original post was an exaggeration of your duties or you are backpedaling.  You ARE in a position to make a difference...not to just sit back and let the chips fall where they may, correct?  Either way, this is my Request for Pre-approval letter that was sent to my insurance company, along with the materials that the facts were gathered from.

PERSONAL REQUEST FOR PRE-APPROVAL

  Name of Insurance Company

Street Address

City, State & Zip Code

 Re:  Sherry Weber

     ID#:  XXXXXXXX

Request for Pre-approval for Gastric Bypass (CPT-4 Code - 43847)

 Note:  (I meet both Milliman and Robertson and U.S. Federal Guidelines.)

     1.  Milliman and Robertson Guidelines for the Gastric Surgery for Clinically Severe Obesity  15 CPT-4:  43847

         AND,

     2.  U.S. Federal Clinical Practice Guidelines for the Treatment of Obesity set down in National Institutes of Health Concensus Conference.  Released June 17, 1998, the Federal guidelines on obesity were by the National Heart, Lung, and Blood Institute (NHLBI), in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

(Date)

 Dear Sir or Madam,

 I am writing to request your pre-approval for gastric bypass surgery (Diagnosis Code 278.01 Procedure Code 43847).

 I am 5 feet 6 inches tall and I weigh 301 pounds.  My Body Mass Index is 48.6.  The Body Mass Index is calculated by dividing a person's weight in kilograms by their height in meters squared.  When a man's BMI is over 27.8, or a woman's exceeds 27.3, that person is considered obese.  The degree of obesity associated with a particular BMI ranges from mild obesity at a BMI near 27, moderate obesity at a BMI between 27-30, severe obesity at 30-35, to very severe obesity for patients with a BMI of 40 or greater.  (1,2,3)  Therefore, I am classified as being very severely obese.  The annual number of deaths in America attributable to obesity has been estimated to be 300,000 deaths per years.  (4,5)  With an abnormally high BMI, I am at an estimated 110 percent increased risk of death at my present weight.

 I ask for your pre-approval for this surgery.  I will detail the issues of medical necessity.

 I feel I need to let someone out there know a little about myself.  I am one of many people that you will never have the pleasure of meeting.  I am not a bad person, just a severely obese person.

 I have battled my weight problem for many years and was both nervous and excited at the prospect of writing this letter.  I knew that it would be the first time that requesting help for both my medical and weight problems would actually result in success.  I spent considerable time researching the surgery and processing and weighing all the information.  I considered the long-term effects, the necessary dedication relating to the success of the outcome, and how my life would change.

 In the past, I have felt like a failure, in terms of weight loss.  I have tried diets, fad diets, fasting, and medically supervised diets.  This was a long and painful decision.  It has taken a lot of prayer, thought, and research to come to the point of requesting gastric bypass surgery.  And I really came to peace with my decision and decided that I was strong enough to do what I needed to do in order to change my life.  I am asking that you help give me back the quality of life I yearn for.

 I am having significant adverse symptoms from my obesity.  I have difficulty standing for more than a short period of time, and in doing any kind of exercise, even walking more than a short distance.  I have difficulty performing many daily activities and in participating with my family in recreational activities.

 I have sleep apnea.  Sleep apnea--the stoppage of breathing during sleep--is common in the clinically severe obese.  The health effects of this condition may be severe.  It has been estimated that up to 50 percent of sleep apnea patients have high blood pressure.  Risk for heart attack and stroke also increase in those with sleep apnea.  People with sleep apnea often feel very sleepy during the day and their concentration and daytime performance suffers.  The consequences include depression, irritability, sexual dysfunction, learning and memory difficulties, and falling asleep while at work, on the phone, or driving.  This condition has a high mortality rate, and is a life-threatening problem.  People are usually cured of sleep apnea by this surgery and the permanent weight loss it brings.

I am insulin resistant, which is a pre-cursor to Type II Diabetes.  In addition to being a morbid and lethal disease, diabetes has been shown to be very expensive to treat.  Rubin et. al. in a study in 1992 showed that yearly health care expenditures for confirmed diabetics ($11,157.00) were more than four times greater that for non-diabetics.  In 1992, diabetics constituted 4.5% of the U.S. population but accounted for 14.6% of the total U.S. health care expenditures ($105 billion).  Confirmed diabetics constituted 3.1% of the U.S. population but accounted for 11.9% of total U.S. health care expenditures ($85 billion).  Health care expenditures for people with diabetes constituted about one in seven health care dollars spent in 1992.  (Diabetes in America, 2nd Edition, The National Institutes of Diabetes and Digestive and Kidney Diseases, 1995, NIH Publication number 95-1468.)  Health care insurers should take note of these findings.  Gastric Bypass has been shown to cure diabetes and prevent its complications.  Nearly 80 percent of patients with NIDDM are obese.

 I suffer from Polycystic Ovarian Syndrome (PCOS).  Due to this disease, I am insulin resistant, which is a pre-cursor to Type II Diabetes.  Also, due to PCOS, it is also very difficult to become pregnant and I very much want another child in my future, but without attaining a substantial amount of weight loss to ease the symptoms of the PCOS, this will be near to impossible, and I will be destined to be infertile for the rest of my life.

 Because of my weight, I am depressed.  Seriously overweight persons face constant challenges of their emotions:  repeated failure with dieting, disapproval from family and friends, and sneers and remarks from strangers.  They often experience discrimination at work, and cannot enjoy theatre seats, or a ride in a bus or airliner.  There is no wonder that anxiety and depression might accompany years of suffering from the effects of a genetic condition--one which most thin people believe should be controlled easily by will power.  I suffer from depression related to morbid obesity and I am on Bupropion and Xanax to treat it.

 Coronary artery disease is another problem caused by clinically severe obesity.  Severely obese persons are approximately six times as likely to develop heart disease as those who are normal-weighted.  Coronary disease is pre-disposed by increased levels of blood fats, and the metabolic effects of obesity.  Increased load on the heart leads to early development of congestive heart failure, from which I have already suffered once in 2000.  Severely obese persons are 40 times as likely to suffer sudden deaths, in many cases, due to cardiac rhythm disturbances.

 I become short of breath upon little exertion.  I cannot climb even one flight of stairs without stopping, and have a very difficult time performing the ordinary day-to-day duties of living, such as shopping, cleaning, getting in and out of a car or chairs, or to board a bus.  I was once physically active, but at this time, I am finding that I am unable to perform any recreational activity, and feel depressed because I cannot control or lose the weight.  Climbing stairs or even walking short distances causes the obese to become very short of breath.  Obese persons find that exercise causes them to be out of breath very quickly.  The lungs are decreased in size, and the chest wall is very heavy and difficult to lift.  At the same time, the demand for oxygen is greater, with any physical activity.  This condition prevents normal physical activities and exercise; often interferes with usual daily activities, such as shopping, yard-work or stair-climbing, and can be completely disabling.  Losing weight will cure respiratory problems.

  I have made many attempts to lose weight.  Specifically, in the last two years, Weigh****chers, Jenny Craig, Slim Fast, Herbalife, Optifast, a high protein/low carbohydrate 1200 calorie diet, and currently, The Atkins Diet, and many over-the-counter diet plans.  Prescription and over-the-counter diet medications are contra-indicative, due to my thyroid disease; all of which have been supervised by my physician.

 I have included exercise with all of my weight loss attempts.  I can lose some weight, but then I gain it all back, and more.  There is not one study that shows that dieting brings permanent weight loss.  The National Institutes of Health, in 1991 and 1992 consensus statements, rebutted conventional diets for morbid obesity, and pointed to this important fact:  Diets alone cannot be successful for the morbidly obese.

 Obesity has been shown to directly increase health care costs.  In an article in the March 9, 1998, issue of the Archives of Internal Medicine 17, 118 of the Kaiser Permenente Medical Care Program were studied to determine the association between body fatness and health care costs.  The results showed that patients with BMIs greater than 30 had a 2.4 times greater risk for increased inpatient and outpatient costs than patients with BMIs under 30.  For patients with BMIs greater than 30, the study also showed increases in health care costs related to diabetes and hypertension.

 Americans spend an additional $33 billion annually on weight-reduction products and services, including diet foods, products and programs.  Most of these expenditures, as is evidenced in my case, are not effective.  Rather, it can be expected that I will continue to gain weight over the ensuing years and add to this present list of obesity-associated illnesses.

 Seriously obese people suffer inability to qualify for many types of employment, and discrimination in employment opportunities, as well.  They tend to have higher rates of unemployment, and a lower socio-economic status.  Ignorant persons often make rude and disparaging comments, and there is a general societal belief that obesity is a consequence of a lack of self-discipline, or moral weakness.  Many severely obese persons find it preferable to avoid social interactions or public places, choosing to limit their own freedom, rather than suffer embarrassment.

 I have included three attachments with this request.  The first is my family medical history, the second is my physician-supervised weight loss/diet attempts for the past two consecutive years, and the third shows how I meet your specific required criteria to qualify for gastric bypass surgery.

 I want to be around for a long time to take care of my son and to provide him with the love and support he so deserves.  I want to do things that a mother should be able to do with her child--play in the park, sit down on the floor and play games, go to amusement parks, go to the zoo, to name just a few.  I cannot do these things with my son today, and it is my son who is suffering.  He begs me to ride bikes outside with him, I can't.  He begs me to play tag with him at the park, I can't.  He begs he to go ice skating with him, I can't.  Please, help me to be able to do these things, and more, with my son.

 I do not want the surgery just so I can look great.  I need it for health reasons, as you can see.  I ask that you pre-approve this surgery so that I can become a healthy, productive person once again.

 I trust this information will aid you in understanding the true severity of my case and in facilitating the proper assessment.  Please feel free to contact me if I can answer, or clarify, any questions you might have.

 Footnotes:

 1.  Weighing the Options:  Criteria for Evaluating Weight Management Programs.  Institute of Medicine.  National Academy of Sciences.  1995:50-51

 2.  Kucmarski, R.J., Johnson, C.L., Flegal, K.M., Campbel, S.M.  Increasing prevalence of overweight among U.S. adults.  Journal of the American Medical Medical Association.  1994:272: 205-211.

 3.  Troiano, R.P., Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell, S.M.  Overweight trends and prevalence for children and adolescents:  The National Health and Nutriton Examination Surveys.  1963 to 1991.  Archives of Pediatrics and Adolescent Medicine, 1995:149:1085-1091.

 4.  Daily dietary fat and total food-energy intakes:  Third National Health and Nutrition Examination Survey, Phase I, 1998-1991.  MMWR Morbidity and Mortality Weekly Report.  1994: 43:116-117, 123-125.

 5.  Weight control:  What works and why.  Medical Essay.  Mayo Foundation for Medical Education and Research, 1994.  

Thank you very much for your consideration.

 Sincerely,

  Sherry A. Weber

Attachments

This is a hard one even though it really shouldnt be that hard. My personal experience has been that I tried for over 4 years to have my insurance pay, including taking a job out of my field of training for the insurance that still didnt cover it and ended up self paying. My insurance does state that they will cover any complications of my surgery so I knew I had a cap on costs myself. I presented a report to my insurance company including all my obesity related costs to them over the previous year and showed them that the surgery would pay for itself within 18 months. I didnt even have very serious complications of obesity; I had high blood pressure, high cholesterol, asthma, back pain and injury and I had broken my leg falling (would not have broken if 250 lbs hadnt fallen on it). They still wouldnt cover it. I think you have a unique opportunity here to be an advocate, will you choose to be one? I personally would have stayed with the other company I worked for if they had covered my surgery, not everyone would do that. My sister, on the other hand, was approved on her first try. Why? Union insurance. Unions, where the worker has the right (among others) to be fairly and adaquately insured and in return the employer gets trained and loyal workers (again, among other benefits).  Theres a lot of truth in that statement. I dont know your company but would contracts be an option? The company offers better benefits in return for reassurance of a certain length of employment?  Good luck, Annette

Sherry, I am really sorry you feel I am not being honest. I do not read where I said I was the end decision maker or the sole decision maker. I said I am in a position to represent the best interest of my company. I am sorry you saw that as my being dishonest.

Where did I say that you were the sole decision-maker or that the 'buck stops with you'?  You ARE in a position to advocate for the inclusion of WLS benefits, though...something that you have already decided not to do.   I'll save my breath...you only want people that will tell you it is alright to 'sell out', which I *think* you know you are doing, or you would not have posted this to begin with...

I wonder why this particular type of surgery carries such a stigma.  I don't see exclusions or huge copayments for heart surgery or joint replacement surgery or cancer surgery or cataract surgery.  Morbid obesity is a disease and surgery is a treatment for it.  This surgery is just as life-saving as all the others, yet it continues to be excluded or penalized, with many hoops to be jumped through in order to get it approved.  Also many insurance plans don't cover other forms of assistance that might help someone lose weight such as the services of a nutritionist or trainer. My policy covers employees and their families.  Heart surgery or joint replacement surgery is covered for employees and their families, no special restrictions, with an inpatient hospitalization copayment of $150.00.  All the requesting physician has to do is call in to get authorization.  Gastric bypass surgery is covered only for employees, and it comes with a $3000.00 copayment (in addition to the inpatient hospitalization copayment).  And WLS requires many more pre-op tests and months of documented evidence that the patient followed yet another diet that didn't work. I think it really is discriminatory.

tanissen- You may find this recent study to change you and your employers view: Study finds overweight workers cost employers more What the WLS community must convey to employers and insurance companies is that they are all fishing out of the same pond.  Yes, an employee very well may have WLS only to a short time later leave the company.  It's just as likely, if not more likely, that an employer will unkowingly hire a healthy person who has had WLS. Same applies to the insurance companies.  Obviously it varies on a case to case basis but as a whole they will "save" (pocket even more) money by granting WLS in appropiate cases.  Sure, they may not cover that person for the rest of their life but they will also bring in new accounts/customers who have already had WLS paid for by another insurance group. That's what we must pound into their heads.

The problem is that organizations do not see anything other than their own bottom line. Understanding how important shareholders are and how their best interest far supasses that of employees is key. The fiscal year bottom line, ROI, and attracting investors is more important than any one employee. Is it fair? Probably not, but it is reality. I do not like it and it will never be a comfortable position for me, but I need to make a living and I can benefit people in many other areas if I learn to swallow this difficult crap.

It is true that your company may pay for bariatric surgery for an employee who then turns and leaves the company, and then the company does not benefit from that employee's good health.  It is also true, however, that an employee could have surgery prior to becoming employed at your company, using an insurance company that understands the long-term health benefits, but then left that job and that policy to work at your company. The bottom line is that it is proven over and over that this surgery provides numerous and significant health benefits to the people who have it.  ALL insurance companies and employers who provide coverage should step up to the plate.  If every insurance company paid for the procedure, all insurance companies would benefit, regardless of where a particular employee ended up working. If we can't be strong advocates for this surgery in the face of contrary opinions, who will be? Tess