tomandlu

For those that have bariatric surgery benefits with United Health Care, they now approved Vertical Sleeve Gastrectomy!!!! Hooray!!!! Here is the language from their Bariatric Medical Policy, dated 12/20/2007 that was in effect before 9/17/2009:The gastric sleeve procedure (also known as laparoscopic vertical gastrectomy or laparoscopic sleeve gastrectomy) when done alone and not a part of the full operation to complete a biliopancreatic diversion with duodenal switch is unproven due to inadequate clinical evidence of safety and/or efficacy in published, peer-reviewed medical literature. Here is the language from the UHC Bariatric Medical Policy dated 9/17/2009: The gastric sleeve procedure (also known as laparoscopic vertical gastrectomy or laparoscopic sleeve gastrectomy) when done alone and not a part of the full operation to complete a biliopancreatic diversion with duodenal switch (BPDDS or DS) is proven in adults for the treatment of clinically severe obesity as defined by the National Heart Lung and Blood Institute (NHLBI). Hooray hooray hooray!!! I've been so busy doing research, drafting appeals and feeling frustrated and miserable. On Monday I am calling my surgeon back to get a DATE!!! Luanne

I had VSG surgery 11/3, UHC approved. BMI between 35 and 40 w/diabetes, sleep apnea, hypertension. UHC's medical policy is available on the web - PM me with your email address and I will send it to you if you can't find it. The issue may be in what they define as a 'co-morbidity'. Good luck!

The diet part is an interesting question. It has it in the new bariatric policy, but several folks have told me that that is something that is a part of the agreement between the company and UHC. As it turns out, my 2nd appeal was approved with out any additional requirements. In the 'Coverage Rationale' section, it has the following that is new: Additional Information Patient selection criteria for bariatric surgery includes: l Documentation of a structured diet program which includes physician or other health care provider notes and/or diet or weight loss logs from a structured weight loss program for a minimum of 6 months. l Active participation in an integrated clinical program that involves guidance on diet, physical activity and behavioral and social support prior to and after the surgery. l Psychological evaluation to rule out major mental health disorders which would contraindicate surgery and determine patient compliance with postoperative follow-up care and dietary guidelines.

I just heard from my surgeon's office and UHC - my VSG has been approved on my 2nd appeal... now it is just waiting to schedule a date. Whew - this will sure make the weekend a bit easier to relax!

Thanks all! I am so ... excited/elated/little scared/apprehensive/amazed! My date is 11/17 and my surgeon is Emma Patterson in Portland, OR Cheers everyone! Luanne

I think that the clincher will be your BMI w/no comorbidities... That might be a harder fight than getting them to cover VSG. If you can get their medical policy and find out what they consider a comorbidity - that varies widely, from type II diabetes to high cholesterol. If I had a choice between fighting insurance or going self pay - I'd go self pay ASAP! Good luck, Luanne

Thanks for the encouragement Sheri - yes, I am going to try that. Show them my 5 years of cancelled checks and my doctor's notes. I have also been sent to nutritionists 3 times - I am wondering what person in our shoes has not been on several "structure weight loss" programs before going for surgery? I'm not giving up, but I am mightily discouraged. I ended up taking two days off from work and just crying last week. I know, silly me.... I believe the NHLBI is a division of NIH. The new UHC policy, IMHO, is significantly better written and referered than the previous one. Luanne

I have no idea. You can always submit, appeal...appeal... several levels of appeal. Heck, it's a lot of money, worth at least trying. Good luck! Let me know if I can help - I'd at least give it a shot. Luanne

*sigh* I over looked this the first time I read the new UHC policy... It is wonderful, it recognizes the sleeve as proven. It now requires 6 months supervised weight loss, " Additional Information Patient selection criteria for bariatric surgery includes: l Documentation of a structured diet program which includes physician or other health care provider notes and/or diet or weight loss logs from a structured weight loss program for a minimum of 6 months. " ... I have done that, I just don't have documentation - it wasn't needed before. I have two years on weight watchers except the records were tossed when I moved last year. I feel so.... defeated. I've been working on getting surgery since March (6 months 1 week). I have lost 30 pounds since talking to nutritionists... but it is not structured enough. I am soooooo.... defeated, frustrated, tired... this process is never going to end. Sorry for the whine folks, it has been a long few weeks of writing appeals - and when I thought I had won they throw another new hurdle at me that is going to take 6 months starting from now.

This is my first appeal. Any feedback welcome, and if it is helpful for anyone, please leverage! UnitedHealthcare Appeals Unit P.O. Box 30575 Salt Lake City, UT 84130-0575 Fax: (801) 938-2100 APPEAL REQUEST Service Ref # XXXXXXXXXXXX Specific Coverage Decision being appealed: Clinical evidence in published peer-reviewed medical literature is insufficient to show that a gastric sleeve procedure by itself is a safe and effective treatment for morbid obesity, thus is an unproven procedure and not covered by benefits. I am requesting an appeal of this decision based on the following: The UnitedHealthcare Bariatric Surgery Medical Policy document approval date is 12/20/2007, and the papers referenced with respect to Laparascopic Sleeve Gastrectomy (LSG) policy are all from January 2007sleep apnea, and the best surgical procedure for me, supported by current peer-reviewed literature, is the vertical sleeve gastrectomy. Supporting Literature A systematic review of the literature covering LSG through January 2009[6] was published in June this year. Conclusion: From the current evidence, including 36 studies and 2570 patients, LSG is an effective weight loss procedure that can be performed safely as a first stage or primary procedure. From this large volume of case series data, a matched cohort analysis, and 2 randomized trials, LSG results in excellent weight loss and co-morbidity reduction that exceeds, or is comparable to, that of other accepted bariatric procedures. The postoperative major complication rates and mortality rates have been acceptably low. Long-term data are limited, but the 3- and 5-year follow-up data have demonstrated the durability of the SG procedure. A handful of additional work has been published since that literature review concluded, with additional long term durability data and adding considerable support to the efficacy of LSG in resolving diabetes.[7],[8],[9],[10],[11],[12],[13] Since the UHC bariatric surgery policy was written, two International Consensus Summits for Sleeve Gastrectomy have been held, the first[14] 10/25-27/2007 and the second[15] 3/19-21/2009. At the second conference, during the consensus part, the audience responded that there was enough evidence published to support the use of SG as a primary procedure to treat morbid obesity and indicated that it is on par with adjustable gastric banding and Roux-en-Y gastric bypass, with a yes vote at 77%. Conclusion Supporting references have been provided which demonstrate Laparoscopic Sleeve Gastrectomy as an effective, durable and proven surgical procedure for the treatment of morbid obesity and associated co-morbidities. Given my long term dependence on steroids, LSG is the best option for me to treat my morbid obesity and associated diabetes, sleep apnea and high blood pressure. I request coverage be granted for the laparoscopic sleeve gastrectomy procedure. Sincerely, xxxxxx xxxxxxxx (Name deleted for privacy purposes) encl References [1] ECRI. Custom Hotline Response. Laparoscopic Sleeve Gastrectomy (LSG) for Morbid Obesity. March 2006. Updated January 2007, referenced in the UnitedHealth Care Bariatric Surgery Medical Policy 12/20/2007. [2] The incidence of a marginal ulcer perforating after Laparoscopic Roux-n-Y Gastric Bypass was significant (>1%) and appeared to be related to smoking or the use of NSAIDs or steroids: E.L. Felix EL, Kettelle J, Mobley E, Swartz D, Perforated marginal ulcers after laparoscopic gastic bypass, Surgical Endoscopy,2008, 22(10): 2128-2132. [3] The Lap-Band System is not approved for people on long-term steroid replacement (LAP-BAND System Information for Patients, pg 6 - Contraindications, Allergan, Inc., 2007) http://www.lapband.c...ntraindications [4] The Realize Personalized Banding Solution is contraindicated for those on long term steroid therapy (Ethicon Endo-Surgery website, patient information) http://www.realize.c...siderations.htm. [5] VGB procedures are essentially no longer performed. Medicare National Coverage Determinations Manual, Chapter 1, Part 2 (Sections 90 160.26): Coverage Determinations [6] Brethauer S, Hammel J, Schauer P, Systematic review of sleeve gastrectomy as staging and primary bariatric procedure, Surg Obes Relat Dis. 2009, 5(4): 469-475. [7] Rosenthal R, Li X, Samuel S, Martinez P, Zheng C, Effect of sleeve gastrectomy on patients with diabetes mellitus, Surg Obes Relat Dis. 2009, 5(4): 429-434 [8] Fuks D, Verhaeghe P, Brehant O, et al. Results of laparoscopic sleeve gastrectomy: A prospective study in 135 patients with morbid obesity. Surgery. 2009;145(1): 106113. [9] Peterli, R, Improvement in Glucose Metabolism after Bariatric Surgery: Comparison of Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy. Annals of Surgery 250(2): 2009 [10] Court I, Bellorin O, Dip F, DuCoin C, Szomstein S, Rosenthal RJ, Evolution of Sleeve Gastrectomy as a primary procedure for weight loss in morbid obesity, Bariatric Times 2009 5(5). [11] Arias E, Martnez PR, Li VKM, Szomstein S, Rosenthal RJ, Mid-term Follow-up after Sleeve Gastrectomy as a Final Approach for Morbid Obesity. Obes Surg. 2009 19(5): 544-548 [12] Eid G, Mattar S, Patel S, Gourash W, McCloskey C, Ramanathan R, Schauer P. Laparoscopic sleeve gastrectomy: 5 year follow-up. Surg Obes Relat Dis. 2009 5(3): S5 [13] Todkar J, Shah S, Shah P, Gangwani J, Weight loss & evolution of co-morbidities & quality of life following sleeve gastrectomy for morbid obesity with type 2 diabetes mellitus: Results at more than 3 years Surg Obes Relat Dis. 2009, 5(3): S52-S53. [14] Deitel M, Crosby RD, Gagner M. The First International Consensus Summit for Sleeve Gastrectomy (SG), New York City, October 2527, 2007. Obes Surg. 2008,18(5):487496 [15] Gagner M, Deitel M, Kalberer T, Erickson A, Crosby R. The Second International Consensus Summit for Sleeve Gastrectomy, Miami Beach, FL, March 1921, 2009, Surg Obes Relat Dis. 2009, 5(4): 476-485.