Question:
Does anyone has a copy of a insurance appeal letter they used to get approval

   — Stephen H. (posted on July 2, 2003)

July 2, 2003
Hi there, I don't personally have a letter, but there is a book about wls by Michelle Boasten (about $12) and it has a really good appeal letter that helps you lay out your medical/health/diet history for the insurance co. Good luck!
   — beeda

July 2, 2003
Check out this letter. I hope it helps. http://www.obesityhelp.com/morbidobesity/m-instrouble.phtml
   — shbama

July 2, 2003
Here's a letter that I used:<p> TO: Your Insurance Company <p> FROM: Xxxxx Xxxxx Xxxxxxx Pol. # xxx-xx-xxxx<p> DATE: May 31, 2000<p> RE: Request for Surgery Approval<p> I am writing to appeal your denial for my recent request for surgical treatment for morbid obesity. The procedure that I will be having, with the surgeon's recommendation of course, is Roux-en-Y Gastric Exclusion. This operation has been shown to have the most beneficial outcomes, with less complications post-operatively than the other options. My surgeon will be Dr. Xxxxxx Xxxx Xxxxxxx at the Bariatric Treatment Center (BTC). I have researched doctors and centers thoroughly and have found BTC to be highly recommended. <p> I want you to know that I am highly motivated, educated and determined and have the skills, desire and tenacity to make this procedure a success. It's not an easy decision to make, and it's not a cop-out in any way....I've struggled for over twenty years and I am tired of struggling. Other than the physical problems I've listed below, there comes with being morbidly obese a very emotional roller-coaster that I live with from day to day......it's hard to explain to someone who isn't obese, but even simple things like having people stare and having to buy clothing at the "fat-store" is humiliating....and this is not even including the emotional trauma of not doing things in life for fear of humiliation....something simple like not attempting to ride a roller-coaster at an amusement park or traveling by airplane for fear of being told you are too big and the safety bar or seat belt will not accomodate your bulk. I want to be healthy and minimize my risks so that I can re-enter life on a full-time basis for myself and for my wonderful family and I know that this is a last resort for me.....as you can see below, I have made many excellent attempts in the past, and now this surgery is medically necessary. <p> I have enclosed letters from my primary care physician, OB/GYN, reproductive specialist, and GI doctor who diagnosed gross reflux and hiatal hernia, a weight log since 1984, a detailed diet and weight loss/gain history since 1984 and copies of the many weight loss plans and books that I have tried over the years. On the Diet and Weight Loss/Gain History I have left out some of the numerous diets that I tried that I found in books and magazines because I did not remember the exact details pertaining to exact dates and wt. lost/gained. I've tried every one I came across, and have included copies of those books. Also enclosed are copies of some of my numerous weight loss plans and nutrition books as well as some scanned photographs of the many others that I've tried over the years.<p> I am 33 years old, 5'6" tall, and weigh 290 lbs. -- which makes my BMI 48.4. My history is typical of the morbidly obese. I have been on the edge of obesity since childhood. I weighed 145# (at 5'6") in high school and was always trying to diet. After graduation, marriage, and having a child, my weight had crept up to just over 200# and since then I have tried every diet plan and over-the-counter diet medication I could get my hands on. By the age of 22, I was up to 230# and at 25, I was at 250#. Over the past 5 years I have fluctuated between 245-275# and am now at 290# as of my weigh in last week at my T.O.P.S. group. I will describe the effects and comorbidities in a moment. I have never been on a prescription weight loss medication but have tried everything else imaginable, and with the tragedy of Redux/Phen-Fen, I'm glad I chose not to try this new medication on the market. Most recently I considered Xenacal, but have talked to 12-15 individuals who were on it and reported minimal weight loss and unbearable flatulence and rectal leakage of mucous. <p> Most recently, over the past 9 months to a year, I'm finding that when I climb stairs or even go grocery shopping I get out of breath. Oftentimes, when I answer the phone at home, the caller asks if I had to run to the phone because I'm out of breath just from jogging through my small, 1000 sq. ft. house to the phone. I can do a minimal to moderate exercise program for less than 10 minutes (closer to 5 minutes) before physically not being able to continue. <p> At about 260# the pain in my feet, knees, and back began, but I was able to manage by sitting around a lot. This pain and decreasing mobility interferes with any exercise, my job performance and family/personal life. I'm often the outsider watching as others do many of the routine things of life that I should be able to enjoy, such as sports, and even just having the energy to be outside walking the dogs and being with my family more. Now, when I get up in the morning, my ankles and feet hurt so bad because of my weight that I limp around for 5 minutes until they get used to bearing my weight again.<p> Over the past 2 years, I have been suffering from stress incontinence brought on by my obesity. In fact, in 1997 I dieted and was down to 236 lbs. and the incontinence ceased, only to return when I gained the weight back. Now, I wear sanitary pads whenever I am going to be doing anything more than just sitting around the house. Added to my gross reflux and hiatal hernia that I was diagnosed with 3-4 years ago, I'm now experiencing reflux when sleeping that takes my breath away and also symptoms of sleep apnea (extremely loud snoring, involuntary twitching, and feeling just as tired in the morning as I did when I went to bed). As of today, June 1, 2000 I have been diagnosed with mild to moderate obstructive sleep apnea and severe pathological daytime sleepiness as a result of the sleep apnea. I will have my CPAP titration study on July 1st.<p> Over the past several years I have been Amenorrheic and have been unable to get pregnant after consultation with both my OB/GYN and also a Reproductive Specialist. I now take Provera every three months so that I have a menstrual cycle. Through consult and testing with the repro. specialist, we had decided to try some medications and insemination for pregnancy, but I have decided that to get pregnant at this weight would be a risk for myself and a child. Through testing at the reproductive specialist, I was found to be Insulin Resistant, which is a precursor for Diabetes, and can be remedied by losing weight.<p> I am a Registered Nurse and, because of decreasing mobility for certain things, I often have a difficult time bending over and performing job duties for my patients, and often worry about what would happen if I had to try and do CPR to a patient on the ground.....as it is, I grunt and groan, as well as huff and puff when bending over or squatting down. <p> I have made numerous attempts to achieve weight loss by dietary means and have been on the following diets, weight loss programs, medications, and exercise programs: 1200 and 1500 calorie diet plans, Weight Watchers, T.O.P.S., Health Club Memberships, Richard Simmons, Fit for Life, Sugar Busters, McDougall Program, Eat More, Weigh Less, Your Perfect Weight by Prevention, the 5 Day Miracle Diet, the Pritkin Diet, the Weigh Down Diet, This is Living, The Feel Full Diet, Dieting with the Duchess (Weight Watchers), Eat Great & Lose Weight with Suzanne Sommers, Atkins Diet, and the Rotation Diet... and every plan on the book shelf, newspaper or television. Diet Products and Plans: Metabolife, Slim Fast, Dexatrim, Accutrim, ADA diet plan, cabbage soup diet, grapefruit diet, and any other diet, fad or otherwise, that came along. I've been involved with weight-loss support groups over the internet and at work with routine weigh-ins. Gyms and Exercise Programs have included: Vic Tanny, private gym, home gym, aerobics classes at home and at local clubs, water aerobics, Billy Blanks Taebo, and Richard Simmons work-out tapes. I actually enjoy the Taebo and Richard Simmons, but my overall physical status keeps me from doing them....I look forward to losing weight and actually being able to have the energy and stamina to exercise!<p> With my BMI of 48.4, I am classified as morbidly obese and have the following comorbidities: Amenorrhea, infertility, extreme fatigue, pain in weight bearing joints including knees, ankles and hips, high HDL/LDL ratio, obstructive sleep apnea with resultant severe pathological daytime sleepiness that interferes tremendously with daily functioning, hiatal hernia, gross reflux, insulin resistance, occasional peripheral edema when standing/walking for a few hours, stress incontinence (which resolved itself when I lost to 236 lbs., but returned when I gained the weight back -- and for this I am reduced to wearing sanitary pads to prevent embarassing accidents), shortness of breath on exertion (1 flight of stairs leaves me breathless), migraine headaches, heartburn, and irritable bowel syndrome. I found a quote from bariatric surgeon Dr. G. Wesley Clark, of San Diego, who works with another bariatric surgeon, Dr. Alan Wittgrove.....he quotes:<p> "Actually, we're finding that more than 95% of all health problems related to obesity are gone within a year of this surgery," Clark continues. "That includes diabetes, gastroesophageal reflux disease, high blood pressure, sleep apnea, weight-bearing joint problems, pain in the low back, and incontinence.....When you get rid of all the problems you've had, it makes sense you've got a better chance of living longer." <p> I know that bariatric surgery is a big decision, but I've done a remarkable amount of research on it. The the procedure is called a Roux-en-Y Gastric Exclusion, and will be done by the Bariatric Treatment Center at their hospital in Ypsilanti, Michigan that is exclusively for this surgery. It is by no means the easy way out, but I feel that I am ready to do this and to make it a success! I'm 33 years old now but I feel like I'm 50.....and even scarier that the thought of having surgery, is the thought of not being around when I'm 50 ~~ I've really come to terms recently with the fact that you don't see very many, if any, fat senior citizens.<p> Between myself and close follow-up with my doctors, I am sure that me and my very supportive family can, and will, make this a success. It's time for me to re-enter life on a full-time basis and be the best that I can be -- for myself and for my family. I believe that all coverage criteria have been met, and in fact, I have provided you with everything necessary. We have met the "medical necessity" criteria and the procedure is not excluded.<p> Enclosed you will find specific information from Bariatric Treatment Center; my psychological evaluation results; sleep study results; EGD results that show gross reflux and hiatal hernia; health history/comorbidities; weight loss programs, meds and exercise plans/programs I've used; a letter to my doctor outlining my plan and associated physical and emotional problems; letter from my personal care physician; letter from my obstetrician/gynecologist; letter from my reproductive specialist; a weight loss history since high school; a diet history since 1986; and photocopies of the numerous books and diets I have attempted. I have made everything complete so that I am sure everything has been covered. If you need anything more specific, please let me know.....though I doubt you will, as I have dotted every *i* and crossed every *t* to make this as thorough and smooth as possible for myself and for you.<p> Thank you for expediting my request and forwarding the authorization as soon as possible to Bariatric Treatment Center. (A faxed copy forwarded with the hard copy to follow would be especially considerate.) Please contact me if you require more information. <p> Sincerely,<p> YOUR NAME
   — Lynette B.