Please tell me what you think of my appeal letter

[sweetiepie01 0]

Dear Sir or Madam,

I am writing this letter to appeal your decision to deny my sleeve gastrectomy surgery with Dr. Minkin.

I received the letter that United Healthcare sent on Feb.24, 2011. I have included a copy of that letter for your reference.

The letter states that I have not met the criteria of "5 years documented morbid obesity."

I am currently 25 years old and have been at least 100 pounds overweight since I was 18. I was referred for this surgery by my PCP, who is very concerned about my health because of severe morbid obesity. I am a 25 year old morbidly obese female who is 5 feet 2 inches tall and weigh 230 lbs., giving me a body mass index of 42.1. (PLEASE SEE ATTACHED DOCUMENTATION FROM MY PCP SHOWING RECENT PHYSICAL WITH DOCUMENTED HEIGHT AND WEIGHT).

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 year^4,5. With my abnormally high BMI, I am at an estimated 190 percent increased risk of death at my present weight.

I have regularly had weigh-ins at my Ob/GYN. I have attached copies of those visits which clearly show that I was morbidly obese every year for the last 5 years. Per United Healthcare’s Care Coordination department, my BMI in 2007 was calculated to be 39. The reason for this change in BMI is due to my constant FAILED attempts to lose weight by diet, exercise, and the use of supplements. Unfortunately, these attempts have all failed me. As you can see from 2006, my BMI was 40 and also I’ve included other visits in 2007 in which my BMI was 40 as well. My weight and BMI has since increased.

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 OB/GYN physician put me on Adipex. 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.

I have also included the original documentation showing that I meet all other criteria outlined by your policy for gastric sleeve surgery. Based on the data included I hope that you will reconsider coverage for gastric sleeve surgery. I have surgery scheduled with Dr. Minkin for March 21,2011.

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 they will continue to gain weight and the costs of co-morbid conditions, including the ones they already have and ones they surely will acquire as time goes on, will far outweigh the costs of gastric sleeve surgery that we are asking you to please approve for me.

The language from the new UHC Bariatric Medical Policy now states: 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).

Your prompt attention is greatly appreciated.

[Kdthomas 0]

Sounds good to me.

[Caliblonde 25]

I love it!

[mctaverne 1]

Sounds good. I plan on using part of it in my own appeal letter. One thing that my insurance company indicated, is that if your PCP recommended you for surgery, you might have her/him write a letter to that effect. Every little thing helps.

[Used2b575lbs 29]

I'm surprised the surgeons office is having you write this letter. I went through 3 appeals with Cigna and my office handled every one of them. The letter does sound good though... Good luck!!!

[Was a humpty dumpty 35]

Looks good. You could also add, I am sending this a last resort, before appealing with - DIFP

http://insurance.mo.gov/consumer/Health/providercomplaints.htm

Good luck.