Insurance Appeal Letter

So I was denied due to the "experimental" nature of the surgery. I decided to appeal and have been working on that. I finally finished my appeal letter. I also requested an appeal letter from my doctor's office about two weeks ago. I plan on mailing it this week. I hope this works. Here is the letter:

To Whom It May Concern:
On August 02, 2010, I was denied coverage for the Vertical Sleeve Gastrectomy (VSG) as a standalone procedure for the treatment of morbid obesity. The reason given for denial was that the procedure is “investigational or experimental” due to not yet being determined as a valid treatment by peer-reviewed literature. In this letter I will offer research results that demonstrate the effectiveness of the VSG, as well as the reasoning behind why this is the best surgery for my problem.
The American Society for Metabolic and Bariatric Surgery (ASMBS) issued an “Updated Position Statement on Sleeve Gastrectomy as a Bariatric Procedure” on November 9, 2009. This statement supported the use of the sleeve gastrectomy procedure as a standalone treatment of morbid obesity:
“Limited intermediate-term (3–5-year) data have been published in peer-reviewed studies demonstrating durable weight loss and improved medical co-morbidities in patients treated for morbid obesity using the [sleeve gastrectomy] SG procedure. The long-term follow-up data at 5 years for high-risk and super-obese patients are limited, in part because some patients undergo a planned second operation (Roux-en-Y gastric bypass or duodenal switch) within 2 years of their SG, either as part of an overall staged treatment strategy or because of weight loss failure or weight regain. Informed consent for SG used as a primary procedure should be consistent with the consent provided for other bariatric procedures and should include the risk of long-term weight gain.”
The ASMBS notes several studies that suggest that due to the fast paced changes occurring in this field, the medical and insurance community should review its statements of denial due to limited supporting evidence of the long-term outcomes of this procedure. Although originally this procedure was not standalone, but rather step one of a two step procedure for the extremely morbidly obese, due to several factors, many of the original participants never underwent stage 2, and maintained weight loss equal to that of other procedures with only the first stage (VSG).
Most importantly, the rates of improvement of secondary conditions such as diabetes, hypertension, hyperlipidemia, and sleep apnea are comparable to those seen in other restrictive only procedure. The rates of complications due to surgery are relatively low and again comparable to other gastric surgeries. The rates of weight loss are higher than that of gastric banding, and comparable to those who received the RNY surgery, both at 1 year and 3 years post-op.
Personally, I am a 37-year-old female in relatively good health (some mild edema, heart palpitations) other than morbid obesity (current BMI is 47). Many people who undergo this surgery have co-morbid conditions that I do not have. I am still young, though, and I have an extensive family history of conditions related to obesity on both sides of my family. Type II diabetes is a disease prominent in my family for at least 3 generations (including my mother and both of her brothers, my father, my maternal grandmother, my maternal grandfather, and my maternal great-grandmother). In addition, both of my parents have further medical problems that warrant disabilities due to secondary complications from diabetes (mother: diabetic neuropathy with Charcot foot syndrome, heart arrhythmias, and 1 heart attack) (father: Myasthenia gravis, diabetic neuropathy, dyslipidemia, hypertension, and 2 heart attacks). Both of my parents were obese but healthy into their early 40’s when they developed type II diabetes and went drastically downhill from there. This is my chance to keep from following the same family patterns. I do not want to wait until I am 45 and suffering from these conditions to finally be approved for this surgery. I want to maintain my somewhat healthy body, and live my life to its fullest.
I have researched all my options extensively and believe that the VSG is the best fit for me. The complications associated with banding, including wear, slippage, fill/port problems and the fact that you have a foreign object within your body for a lifetime, are all negative factors. Even doctors who do joint replacements and other such surgeries note that the lifetime of these type objects is not equal to the lifetime of the patient and will often require additional surgeries after 10 – 15 years. In addition, I am concerned about the mal-absorptive side effects of surgeries such as the RNY. I believe in maintaining a balance of health with exercise and good food choices that match the studies supported by the national health standards. Being unable to process or eat certain foods as well as problems absorbing vitamins is not something I want to do to my body. I believe the restrictive process of reducing my stomach size will allow me to return to the most normal, healthy eating pattern, with fewer calories, but maintain my ability to intake medications, vitamins and a variety of foods. In addition, by retaining my pyloric sphincter muscle, I will not have the problems of the pouch stretching at the bottom allowing food to just “pass through” that many RNY patients are reporting, resulting in a 20-30 pound weight gain, and a follow-up surgery to correct. I know that I can lose weight on a healthy restrictive diet. I have lost 20-30 pounds several times over on healthy restrictive diets such as weight watchers and portion/calorie control using internet food tracking plans. Each such time, it is impossible to maintain as I feel as if I am “starving to death.” The longer I am on the diet, the more intense this feeling becomes. The only time that this did not happen while on a diet was when I took the pondamin/phentermine combination medication. I was able to lose 50 pounds and maintain the weight loss for over a year. Due to the removal of the fundus during the VSG, production of Ghrelin is reduced and often results in the loss of that intense hunger feeling that so often impedes dieting. I believe that this would allow me to restrict my intake, follow a healthy diet, and not feel as if I am “starving to death.” I want to have a normal healthy long life and I believe that VSG is my best chance.

I could use some suggesstions or support.

Insurance - DENIED!!!!!

So, here I was waiting for the call. The one from Dr. Davidson's office (Bariatric Surgery Center of Dallas)to let me know that I was officially approved. When I answered the phone on Monday, I was soooooo happy to hear her say, "This is Dr. Davidson's office" and then WHAM! She told me that although I met the qualifications for both gastric bypass and lap-band surgery, my insurance (Blue Cross Blue Shield of California) does not cover the sleeve. I was overwhelmed by an intense disappointment. I don't want the other two surgeries, and this (the gastric sleeve) is the best one for me. I told my hubbie that I would just go without, but he knows me and said to find out how much self pay is and we will just find a way. So I did, and here we are.

Movie Theater Seats

We usually go to the theater near our house, but the one in Mesquite had better times, so off we went. Anyway, the seats were too small. I could fit, but the arms on both sides were hugging me. I get so embarrassed by things like this. I know that I am big, but I don't feel that big! Luckily, the arms were ones you can raise, so I raised one and watched the movie.

On a more positive note, I haven't laughed so hard at a movie in a long time. Dinner for Schmucks.