Appeal Letter Suggestions

[want2bthin 93]

I have seen some who have posted and were willing to share their appeal letter that helped them get approved. I would so appreciate it if you would inbox me

if you are willing and I will pay it forward.

I was approved by United Healthcare to have my Lapband removed but not to have the Sleeve. I will give them credit in that a Care Coordinator follows

up with me regularly to see how I am doing. I moved to a new state so had to find a new Primary Dr. and saw him for the first time a month or so ago

to officially start a 6 month program which is supposedly the main reason they wouldn't approve. The Care Coordinator also had me talk to a Behavioral Counsellor

and both seem to be very caring and understanding of my situation and have encouraged me to appeal. I do plan on appealing but my former Primary requires me to

send a letter to obtain my records and I have not done that yet - but will do tonight or tomorrow. I did obtain records from my former podiatrist for plantar fascitis treatment records

as well as my former Bariatric doctor to demonstrate the care I had in the past (my last fill was in 09/09 though) after which I pretty much gave up on the whole thing.

Anyway, I want to get started with the Appeal letter and have a good idea of what to say and I have lots of receipts from any number of diet plans I tried even while having the

band due to my lack of weight loss -- WW, Medifast, Nutrisystem, etc. I felt so vindicated when my new surgeon read the results of my Upper GI and saw that the band had slipped

and isn't even sitting on my stomach - it's on my esophagaus which explained why I was never feeling full nor had restriction - though food still got stuck at that point.

Thanks in advance to anyone willing to help.

Susie

[lml32937 65]

I have UHC also but as you know they have many different plans. I can offer this advice- Have EVERY physician you saw, Dermatologist, Primary care, Foot doctor, Endocrinologist, Pulmonologist etc.. write your surgeon a letter stating the medical necessity and also that failure to do something drastic may cause other life threatening issues which may possible incur more cost to them in the long run. They have to be strong in their verbage. The more they have the more ammunition you have to get it covered. It helps also if your surgeon has someone willing to work with you getting all of this stuff done- If you havent seen all these specialist for your- co-morbidities GO SEE THEM!!! Most likely (excuse the assumption) if you are overweight you have stresst to your heart- see a cardiologist- Diabetes or pre-diabetes- possible polycystic ovaries etc.. Thyroid-- see a endocrinologist- EVERY RASH or skin discoloration that may be due to overlapping/hanging skin see your PCP etc... It may take leg work on your part but it may help.

NOW if the sleeve is an excluded benefit on your plan than unfortunately you are probably SOL.... and that sux.. There are some insurances that only pay for band or bypass.... good luck-

[want2bthin 93]

I have UHC also but as you know they have many different plans. I can offer this advice- Have EVERY physician you saw, Dermatologist, Primary care, Foot doctor, Endocrinologist, Pulmonologist etc.. write your surgeon a letter stating the medical necessity and also that failure to do something drastic may cause other life threatening issues which may possible incur more cost to them in the long run. They have to be strong in their verbage. The more they have the more ammunition you have to get it covered. It helps also if your surgeon has someone willing to work with you getting all of this stuff done- If you havent seen all these specialist for your- co-morbidities GO SEE THEM!!! Most likely (excuse the assumption) if you are overweight you have stresst to your heart- see a cardiologist- Diabetes or pre-diabetes- possible polycystic ovaries etc.. Thyroid-- see a endocrinologist- EVERY RASH or skin discoloration that may be due to overlapping/hanging skin see your PCP etc... It may take leg work on your part but it may help.

NOW if the sleeve is an excluded benefit on your plan than unfortunately you are probably SOL.... and that sux.. There are some insurances that only pay for band or bypass.... good luck-

Thanks LML for all of your advice. The Sleeve is definitely not an exclusion - they are mostly honing in on wanting me to be under a physician supervised diet plan for six months. I'm already one month into

that anyway so worst case I should be able to qualify after the beginning of the year even without the appeal.

I like the idea of getting the other Drs to write letters - I have records but will ask for the written support also.

Thanks again.

Susie

[Tiffykins 673]

Here's the 2 I had bookmarked for reference.

Dear Sir or Madam,

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 year^4,5. 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 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 bypass surgery that we are asking you to please approve for me.

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.

Dear Sir or Madam,

I am writing this letter to appeal Regence BlueShield’s denial of coverage for removal of a lap band (CTP 43774) and revision to Sleeve Gastrectomy (CTP 43843). Based on the letters of denial dated April 6 2009, the lap band removal was denied because it was "determined that removal of lap band is not medically necessary” and “treatment of morbid obesity does not meet current BMI requirement of FEP (BMI must be greater than 35)”. The second letter stated that Sleeve Gastrectomy “is experimental/investigational”.

Because you may have based your denial on incorrect or incomplete information, I wanted to submit this letter outlining why I disagree with the denial and why I believe surgery should be approved. In this letter I will address each element of the denial individually but would like to start with a clarification that, although the procedures have been submitted and denied individually; the lap band removal, any adhesion or repair procedures deemed necessary on visualization, and revision from a lap band to a vertical sleeve gastrectomy would most likely be done in a single surgery. Dr. Billing does offer them as two separate procedures performed six weeks apart, but I’ve since learned that the current standard of care for lap band removal and revision is for both to be performed in a single surgery. It appears from the separate denial letters that they may have been considered individually rather than as part of a single course of treatment intended to correct and restore the gastric restriction which was achieved when my original lap band procedure was performed in 2006.

Relevant Medical History

I was diagnosed with morbid obesity with multiple co-morbidities in 2006 and underwent lap band surgery with Dr. Neal of Pacific Surgical in Olympia, Washington on August 14, 2006. My surgery was fully covered under Microsoft’s Premera insurance plan as I met the qualifications of a BMI > 35 with 2 or more co-morbidities. On the day of surgery I had a BMI of 38.2.

My lap band procedure was initially successful and I lost ~75 pounds and had resolution of all co-morbidities. Although I still wanted to lose an additional 20 pounds, I maintained the weight loss until early 2009. In February of 2009 I began to experience pain and difficulty eating and could no longer feel restriction. A fluoroscopy with Dr. Neal revealed significant swelling and inflammation. I was told that there was a serious and potentially dangerous stretching of the stomach pouch. My lap band was immediately “unfilled” and I was put on liquids for two weeks pending follow-up.

Because Dr. Neal’s office is almost 3 hours from my home and he is no longer a preferred provider under my plan, I went to see Dr. Peter Billing at Puget Sound Surgical in Edmonds. A second fluoroscopy performed in Dr. Billing’s office confirmed the swelling along with evidence of a recent dilation and/or slip. Although there appeared to be some improvement in the swelling as a result of the liquid diet, evidence of a problem could still be seen so my lap band was not refilled.

Dr. Billing advised me that even a small slip or dilation is generally an indicator of a failed lap band and that surgical correction or revision is usually recommended to prevent a progression of complications over time. A follow-up endoscopy confirmed his findings and I was strongly advised to revise to the vertical sleeve procedure as an alternative gastric restrictive procedure preferable to replacing or repairing my lap band.

After researching the long-term progression of symptoms and risks associated with lap band slips, pouch and/or esophageal dilation I also consulted with Dr. Paul Cirangle of Lap Band Associates of San Francisco. Dr. Cirangle is a nationally recognized bariatric surgeon often considered one of the foremost authorities in lap band revisions and vertical gastrectomy procedures (see curriculum vitae and related publications at http://www.lapsf.com/dr-cirangle-your-bariatric-doctor-for-weight-loss-surgery.php). He confirmed Dr. Billing’s recommendation. As did the office of Dr. Andrew Hargroder in Louisiana -- also well regarded for lap band revisions and sleeve gastrectomies.

After reviewing my Federal BCBS policy and verifying coverage for both procedures over the phone, I proceeded with preparing for surgery by completing the required consultation with a nutritionist and a psychological assessment and was looking forward to setting a surgery date and the subsequent resolution of my physical symptoms. I was very surprised to be notified of the denial.

Lap Band Removal

As mentioned above, part of the denial was related to an assessment that removal of the lap band is not medically necessary. Given the debilitating and constant nature of my problems with the lap band, the only conclusion I can come to about this assessment is a lack of information. So I thought I’d take a minute to describe my current situation.

After following a liquid diet to reduce inflammation and pain I was advised to return slowly to solid foods. Now that I’m eating in the method approved for lap band patients (Protein first, chew thoroughly, small portions, etc.) I now suffer from chronic pain – the only way to describe it is as if a ball of sandpaper about the size of a small orange is lodged behind my sternum with a throbbing and burning sensation that also radiates up my throat. This pain is present most of the time, often increasing after meals but sometimes present without apparent cause. During the worst incidents, there’s a feeling akin to a knife turning in my chest. All of the GERD symptoms I suffered prior to surgery have returned. In the morning I am generally unable to eat solids and must stick to Protein drinks or other liquids.< /p>

Usually I am able to eat around lunch time and do so with caution. Most foods cause some level of discomfort and pressure. Approximately 1-2 times per week I experience an episode with food that results in severe pain and vomiting. These episodes last from 2-4 hours. The onset of vomiting appears to cause additional swelling which, in turn, blocks my stoma. After awhile I am even unable to swallow my own saliva and the pressure and pain increases as the saliva, food, and increased stomach mucus builds up above my closed stoma. It’s becomes a vicious circle because the vomiting increases the swelling and extends the time that the stoma remains closed. Once I am able to resume liquids I stay on a liquid diet for 1-2 days and then slowly return to solid food over the next 1-4 days depending on my pain level.

This has become the regular pattern of my life. It often interferes with my ability to work and/or take care of my children. I’ve had to pull off to the side of the road because I’m worried that the pain is too distracting for me to safely drive with my children in the car. Other times I’ve had to leave work because the need to vomit every 10 to 15 minutes makes it impossible to perform my job effectively. My symptoms are significant and often debilitating. And I can only imagine the kind of long term damage I’m risking as these problems continue. Being told that I cannot have surgery to remove, repair, and revise to the kind of functioning gastric restriction I had with the lap band prior to these complications is incredibly discouraging. It’s hard to imagine having to live this way indefinitely.

Sleeve Gastrectomy as Investigational

Regence’s claim that sleeve gastrectomy is investigational was surprising given how the Federal BCBS benefits statement reads and the verbal confirmation of coverage for CPT 43843 I received in two separate phone calls prior to the doctor’s submission for pre-approval. According to my research, Federal BCBS began considering VSG a covered procedure in 2008. I have identified >20 VSG patients with Federal BCBS coverage who were approved for the procedure upon first submission. In fact, I’m the only person I’m aware of who has been denied for VSG with Federal BCBS under the investigational determination. Listed below are the surgeons with Federal BCBS patients who have had patients with VSG procedures approved.

[Physician names and contact info removed in case there would be confidentiality concerns. I'm happy to share them privately with blog readers if requested.]

I have been told by Regence that Federal plan coverage doesn’t vary from state to state; the benefit guide applies to all participants in all states. Because Federal BCBS is administered by local offices such as Regence, I believe the investigational determination is most likely the result of a simple communication or processing error. Perhaps Regence has inadvertently applied coverage standards for other local BCBS plans (many would deny VSG as investigation even though Federal BCBS does not). I have been confirming coverage with the doctors and local BSBS administrator for the states listed. For example, Dr. Hargroder’s office confirmed that their Fed BCBS patients have been covered. And a supervisor with BCBS Louisiana confirmed that Federal BCBS has been covering VSG since 2008 and that they routinely approve it as a covered bariatric procedure.

The 2009 benefit plan for the Federal BCBS Basic plan covers: “gastric restrictive procedures, gastric malabsorptive procedures, and combination restrictive and malabsorptive procedures to treat morbid obesity.” CTP code 43843 for VSG is listed as a "Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty.” There is nothing stated in the Federal plan that specifically excludes a vertical sleeve gastrectomy. And any reasonable comparison of the plan benefit statement and the CTP code definition could conclude that the procedure definition matches the procedures covered by the plan.

Please note that this letter doesn’t outline why VSG should no longer be classified as investigational. Because Federal BCBS covers VSG it should not be necessary to present evidence regarding the efficacy and safety of the procedure. It does not seem reasonable for Regence to deny one Federal BCBS patient a procedure that is routinely covered for Federal BCBS patients across the country. However, because I would like to be thorough in presenting my appeal, I have attached more information on the VSG procedure should it be helpful during the review of my case. Please see the attached appendix.

Current BMI

Also noted on the denial letter for removal of the lap band, is that I do not meet current BMI requirements (BMI > 35). The fact that this is specifically given as a reason for denying removal of the lap band is odd. In my research I never identified anyone who was denied a lap band removal procedure and found many patients who were at or near a normal BMI when they experienced problems. A lap band could fail at any point after placement, before a patient has lost weight, or after they get to goal, or somewhere in between. The risks of morbid obesity and rapid weight gain are well known. It’s hard to imagine that Regence’s policy would require a patient to regain weight and return to a morbidly obese state before a lap band can be removed and any damage caused by the lap band repaired -- particularly patients with the type of symptoms I’ve been experiencing over the past few months. As happens with most patients that suffer lap-band complications, my weight has increased. My current BMI is 32.3, about 20 pounds short of a 35 BMI. A few of my original co-morbidities have returned. It’s awful to think that the only way I would be approved for lap band removal and repair, the only way to stop the pain and have revised gastric restriction, is to gain another 20 pounds. I’m already doing everything I can to get control over the 40 pounds I’ve regained, especially challenging given how difficult it is to eat healthy Proteins and vegetables when almost anything but soft or liquid foods initiates the pain, swelling and vomiting I’ve described above.

Although covered under a different plan, my original weight loss surgery was approved by insurance under the same conditions that apply to Federal BCBS: >35 BMI and co-morbidities. I chose a gastric restrictive procedure at the recommendation of my surgeon to avoid the long-term risks associated with malabsorptive procedures like the bypass. Given that I met the criteria and had covered lap band surgery, it seems logical that any subsequent surgeries to repair or revise the original restrictive procedure would be considered a continuation of the initial treatment.

Although not a perfect analogy… If a Federal BCBS patient were to request breast implants, Regence would appropriately deny the claim because such procedures are not covered by the Federal BCBS plan. But consider a breast cancer patient that has a mastectomy. A year after surgery she requests breast implants as part of reconstructive surgery. At the time of her request, the patient is in remission with no active tumor or cancer. Would she be denied the implant surgery because she no longer suffers from cancer? No. Her surgery would be considered a continuation of treatment related to the original surgery for a covered condition.

I respectfully submit that my request can be viewed in a similar light. I was approved for a gastric restrictive procedure with a BMI > 35 and multiple co-morbidities. The lap band surgery was an appropriate treatment for my diagnosis of morbid obesity. The proof is found in the fact that it treated my morbid obesity by bringing my weight into a healthy category and improving my health and quality of life. The lap band has now failed and I have no gastric restriction, and what’s more, now have recurrent and often debilitating pain and side effects. I am asking that follow-up treatment for the original lap band procedure be approved so that the lap band can be removed, any damage repaired, and the gastric restriction previously achieved with the lap band can be restored by a revision to a vertical sleeve gastrectomy. I can think of no other health condition where correction of a failed procedure would be denied, particular if the original procedure also caused additional health problems. Federal BCBS covers gastric restrictive procedures and has covered VSG as an approved gastric restrictive procedure in every case that I was able to identify in my research.

In summary

Based on the information outlined in this mail, I am asking Regence to reconsider the denial and approve coverage for the surgery. If you need any additional information, please contact me at (425) 273 6006.

Thank you for your time.

Sincerely,

Britt

[want2bthin 93]

Those are both great. Thank you so very much for sharing!

Susie

[Wheetsin 714]

If you can, scan or retype your denial letter here. Knowing the exact verbiage of the grounds for their denial will help. You will want to appeal based on the grounds of your denial. A generic appeal may or may not address the specific reasons why you were denied.

[want2bthin 93]

Thanks for asking and any other suggestions you may have.

Here is the specific wording in the denial letter:

"Diagnosis: esophageal reflux,vomiting, abnormal weight gain

Type of treatment: longitudinalgastrectomy

The service is not recommended asmedically appropriate for the following reasons(s):

Authorization for Sleeve Gastrectomy isnot recommended, as clinical criteria for this procedure are not met.For example, per SPD: Recent history and documentation in MD notesthat the pt has participated in and reasonably complied with at least1 physician-supported weight loss program (including nutritionalanalysis, education and regular clinical encounters with a healthprofessional), documented by a physician who does not perform weightloss surgery, lasting for a minimum of six (6) cumulative months andoccurring within two years prior to surgery. Also dietary therapy,i.e., restricted calorie diet, increased physical activity i.e.,exercise program, behavioral therapy to reinforce dietary therapy andincreased physical activity."

[adamsmom 4]

Excellent letters thanks for sharing them!

Here's the 2 I had bookmarked for reference.

[want2bthin 93]

Well I finally did it. I mailed my Appeal Letter on Tuesday - it took quite while to get some of my former medical records from NY. According to UHC's policy they will respond within 15 days for denials prior to surgery being done vs. 30 if the surgery was already done. So I am hoping and praying the letter convinces them.

I was able to take advantage of the helpful info others shared so a HUGE THANKS to those of you who responded.

When I get the final decision - and hopefully a positive one - I will be happy to share my letter to those who are interested via email.

I really hope to be able to move forward in the process. Considering the denial was based on not having the 6 months physician supervised weight loss program - and I'm now already almost 3 months into that, worst case I should be approved when I complete that in mid February. I strongly feel that I shouldn't have to do that considering I lived with the Lapband for 5+ years and they already approved removing that but denied the sleeve because of not having the 6 months pre-op diet.

I'll keep you posted on the response.

Thanks again - I am so glad I found this Board - I have and continue to learn so much from the posts here.

Susie