My Appeal Draft W/references

[tomandlu 0]

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.

[Tiffykins 673]

I am not familiar with appeal processes, but your letter is very concise, and you have amazing reference/resources. I wish the very best for you during the appeal process.

[queenborg 0]

Best of luck! I had 5 appeals with UHC this year and was denied (even though they had previously approved 5 folks in Cisco who had the exact same operation and two in same year. I even had obesity law involved and hoping to go back next year and appeal again after baby is born (near end of appeal found out expecting!)

Word on street is a new director and they are stopping them by using the experimental approach. Also because there isnt a specific medical code given to VSG yet they are using that as a block out for any prior surgeries done.

Hopefully the American Association will put out a new policy this year. Word from my lawyers is hoping for a medical code too and once thats approved be easier process. I'm like you - approved for all others but need VSG for health reasons as dont have a spleen and anemia. Happy to share letters my team did with you offline if you want as well - I had 32 pages of abstracts as well but love the ones you included too

Kindest Regards

Sinead

sinead@chroi.com

[DrPleatman 3]

Good news from United Healthcare. They now cover Vertical Sleeve Gastrectomy the same as they would for any other bariatric operation. This is a milestone, as they are the first insurance company to accept VSG as being an effective "stand-alone" operation for treatment of severe and morbid obesity.

Mark Pleatman MD

Mark Pleatman MD Weight Loss Surgery Website

248-334-5444

[*susan* 1,709]

That is great news, Dr. Pleatman. Thank you so much for letting our members know!

[thinoneday 445]

Good news from United Healthcare. They now cover Vertical Sleeve Gastrectomy the same as they would for any other bariatric operation. This is a milestone, as they are the first insurance company to accept VSG as being an effective "stand-alone" operation for treatment of severe and morbid obesity.

Mark Pleatman MD

Mark Pleatman MD Weight Loss Surgery Website

248-334-5444

Except in my case. I have United HealthCare but it does not cover VSG or any bariatric operation for that matter. They told me it was because that is what the employer has chosen. It really is dissappointing especially since I work for the City Health Dept and our medical director is always harping on weight loss and the obesity rate increasing in our area, then when they changed to UHC, they didn't want bariatrics at all on it. . . .go figure????:glare:

[Malaika 50]

Except in my case. I have United HealthCare but it does not cover VSG or any bariatric operation for that matter. They told me it was because that is what the employer has chosen. It really is dissappointing especially since I work for the City Health Dept and our medical director is always harping on weight loss and the obesity rate increasing in our area, then when they changed to UHC, they didn't want bariatrics at all on it. . . .go figure????:glare:

I have the same restriction on my UHC insurance - apparently the premiums are less if they exempt WLS. That's why I was self-pay and went to Dr. Aceves.

[*susan* 1,709]

I wonder if employers have ever stopped to think that if they include WLS in their insurance coverage, their premiums might actually go down. Think of all the health problems we resolve/avoid by losing weight.

[thinoneday 445]

I wonder if employers have ever stopped to think that if they include WLS in their insurance coverage, their premiums might actually go down. Think of all the health problems we resolve/avoid by losing weight.

That is sooooo totally true Susan! it's really too bad that money is such a driving factor. . . even these surgeries with the wild costs. . .like they say "there is a fortune in fat" . . . but hopefully after this surgery I won't be a fortune anymore!:thumbup: