Question:
Help with appeal letter

Okay, here goes My husband and I were both approved for gastric bypass in July. We have the letters stating it. Now at my hubbys pre-op visit they call and say there not paying. We did not submit all info. They said we need 3 years supervised diet. I have not been to my pcp in over 6 years. I just deal when I get sick. We both have back problems, gerd, gallstones, and swelling. I mentioned all this in the appeal letter and explained how this surgery will save our lives cause of all the family history. Will that be enough to get us approved. Thanks.    — jennie_jen (posted on October 8, 2003)

October 9, 2003
The new bariatric recommended guidelines state that they are only going to require one 26 weeks doctor supervised diet within the last 12 months in order to meet qualifications; in addition to your diet history of what you have tried in the past and how you did on it. Now, every precert company has their own guidelines. I do medical review for precertifications and I have never heard of any company requiring 3 straight years of documented dieting in order to get approval, they usually want a dieting history, but 3 continuous years of dieting, that amazes me. Also, as a general rule, when an insurance company sends you a predetermination letter stating something has been approved, they can't change their minds after the fact and state you now have to do something more to get approved. Are you sure the letter SPECIFICALLY states your gastric bypass is approved? There may be a misunderstanding somewhere. I would go over the letter with your precert person at the mdo and find out if maybe the letter isn't what you think it is, and if not, there is a good chance they didn't give all the info needed. It sometimes takes 2-3 calls from the mdo to get everything needed to review for this surgery. So don't give up!!! I wish you all the best and good luck in your journey. karen morris
   — Karen M.

October 10, 2003
BCBS, as of November 1, 2003, requires three years of constant doctor supervised diet before approving wls. If your insurance changed their policy before you actually had surgery, they can sure deny it even with the prior approval letter. You need to find out what they changed, when, how, etc. in order to do a decent appeal. Good Luck!
   — Sharon m. B.

December 18, 2003
HOPE THIS HELPS--COPY/PASTE THIS TO MS WORD TO REWORD FOR YOU NEEDS. Dear Sir, This letter is to appeal your denial for RNY gastric bypass surgery (Diagnosis Code 278.01 Procedure Code 43847). I was referred for this surgery by my PCP, who is very concerned about my health because of severe morbid obesity. I am a ___ year old morbidly obese male who is ______tall and weigh ______ lbs., giving me a body mass index of________. 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 1,2,3. Therefore, I may be 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 year4,5. With my abnormally high BMI, I am at an estimated 190 percent increased risk of death at my present weight. I am having significant adverse symptoms from my obesity. I have difficulty standing. I have difficulty performing my daily activities, and in participating with my family in recreational activities. I have arthritis and pain of my weight-bearing joints.. An increase in body weight adds trauma to weight bearing joints and excess body weight is a major predictor of osteoarthritis of the knees. This is a mechanical problem and not a metabolic one. Weight loss will markedly decrease the chance of developing osteoarthritis. I also suffer from shortness of breath. There are several abnormalities in pulmonary function in obese individuals. At one extreme are patients with so-called Pickwickian syndrome, or the obesity-hypoventilation syndrome, which is characterized by somnolence and hypoventilation; it eventually leads to cor pulmonale. In patients who are less obese, there is a fairly uniform decrease in expiratory reserve volume and a tendency to reduction in all lung volumes. A low maximum rate of voluntary ventilation and venous admixture is also present. As an individual becomes more obese, the muscular work required for ventilation increases. In addition, respiratory muscles may not function normally in obese individuals. Because of my acid reflux and pains and aches in my back and legs I have difficulty sleeping, and therefore, am fatigued and tired during the day. This surgery usually cures acid reflux and sleep disturbances. I have borderline hypertension at this point. Hypertension is a common concomitant of obesity. I now have bone spurs on both my feet that are aggravated by my weight. I have made many, many attempts to lose weight and this has gone on all my life. I was put on medications by my doctor to help lose weight. I have been put on medications over and over again. I would lose some weight then gain it all back, and more. I have also tried many exercise programs. I have tried Nutri-System. My primary care physician put me on Redux. As you can see, I have spent all my adult life trying to lose weight. I am now at the very edge of complete disability and am at a point where everything is an effort. The obese individual has functional impairment in the activities of daily living. This dysfunction impacts sleep, recreation, work and social interactions. Economic costs of Obesity: 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. Indirect costs: 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 this case, are not effective. Rather it can expected that he will continue to gain weight and the costs of co-morbid conditions, including the ones he already has and ones he surely will acquire as time goes on, will far outweigh the costs of gastric bypass surgery that we are asking you to please approve for this gentleman. As you can see I have exhausted all the traditional ways to lose weight. The gastric bypass is an approved and proven means to permanently lose weight. Please approve this surgery for me. Thank you. Sincerely, Reference Sources: 1. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Institute of Medicine, National Academy of Sciences. 1995; 50-51. 2. Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell, S.M. Increasing prevalence of overweight among US adults. Journal of the American Medical Association. 1994; 272:205-211. 3. 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. 4. 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. 5. Weight control: What works and why. Medical Essay. Mayo Foundation for Medical Education and Research, 1994.
   — A M.