Letter of Approval/necessity

Tell me what you think and any changes that I might need!!


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

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 ft 0 inches tall and I weigh 259 pounds. My body mass index is 50.5. 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 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

I have family members who are obese. My mother, *****cently passed from Chronic Obstructive Pulmonary Disease, She was obese along with high blood pressure and high cholesterol. My Father is also obese with diabetes, high blood pressure, high cholesterol and arthritis. My sister is also obese with the onset of arthritis. I have a lot of other family members that are obese with health problems.

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

I have gastro esophageal reflux disease (GERD). This condition is dangerous, because of the possibility of pneumonia or lung injury. The esophagus may become scarred and constricted, causing trouble with swallowing. Approximately 10–15% of patients with even mild sporadic symptoms of heartburn will develop a condition called Barrett's esophagus, which is a pre-malignant change in the lining membrane of the esophagus, a cause of esophageal cancer. Pathologic conditions associated with GERD include arrhythmia, isolated erosion, confluent erosions, circumferential erosions, deep ulcers, esophageal stricture, and replacement of normal esophageal epithelium with abnormal (Barrett's) epithelium, pulmonary aspiration, chronic cough, and reflux laryngitis.

One of the nearly intolerable problems is the constant pain of the weight-bearing joints. An increase in body weight adds trauma to weight bearing joints and excess body weight is a major predictor of osteoarthritis. This is a mechanical problem and not a metabolic one. The hips, knees, ankles and feet have to bear most of the weight of the body. These joints tend to wear out more quickly, or to develop degenerative arthritis much earlier and more frequently, than in the normal-weighted person. Eventually, joint replacement surgery may be needed to relieve the severe pain. Unfortunately, the obese person faces a disadvantage there too — joint replacement has much poorer results in the obese. Many orthopedic surgeons refuse to perform the surgery in severely overweight patients. The permanent weight loss of gastric bypass surgery will markedly decrease problems with arthritis and the ever-increasing expenses to the insurance companies that will surely follow.

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

Coronary artery disease is another problem caused by clinically severe obesity. Severely obese persons are approximately 6 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. Severely obese persons are 40 times as likely to suffer sudden death, in many cases due to cardiac rhythm disturbances.

I become short of breath on any 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, playing sports and enjoying gardening, but at this time I find 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 person 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 chronic skin problems. I am in a constant battle with yeast infections and chronic rashes in the folds of my body. The obesity causes these skin folds so that skin rubs on skin and the moisture trapped in those creases causes the infections and rashes.

I have made many attempts to lose weight, including:

I have included exercise with all 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.

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 members 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 dollars 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 persons 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 socioeconomic 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 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. Thank you very much for your consideration.

Sincerely,

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

Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell, S.M. Increasing prevalence of overweight among US adults. Journal of the American Medical Associatio*****; 272:205-211.

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

Daily dietary fat and total food-energy intakes: Third National Health and Nutrition Examination Survey, Phase I, 1988-1991. MMWR Morbidity and Mortality Weekly Report. 1994; 43:116-117, 123-125.

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