ThinnerTimes - Gastric Bypass and Lap Band® Forum - View Single Post

Baron Patrick · 12-04-2006, 12:41 PM

Hi Friends;

Well, here is the first draft of my appeal. I'd like your feedback, let me know what you think.

Thanks!

As stated in the denial letter by XXX, MD, “based on the information provided by the requesting provider/physician, you do not meet the established medical necessity criteria or guidelines for laparoscopic roux-en-y gastric bypass at this time.”

“Per CIGNA Clinical Guidelines, coverage is provided for bariatric surgery when all of the following criteria have been unequivocally met:”

“A body mass index consistently 40 or greater for a period of at least one year or a BMI of 35 or greater with evidence of significant other ailments (co-morbidities) such as uncontrolled hypertension, uncontrolled diabetes, or severe heart disease that are associated with obesity (comorbidities) that have defied conventional on-surgical treatment.”

I have been obese literally all my life, with an adult BMI consistently between 45 and 50. My current BMI is 45.5. It is difficult to express how obesity has diminished my quality of life, my health, finances, and opportunities I have missed. I have worked hard all my life trying to lose without long term results. I’m certain your medical professionals have read countless articles, studies and medical literature concerning obesity, and the obvious health effects. I am no different. As you know, obesity not only diminishes one’s quality of life, but also reduces the individual’s life span. I am 48 years old. I do not believe it is necessary to expand on this.

Based on your criteria, I am not required to prove co-morbidities since my BMI is over 40. However, in order for you to make an informed decision, I must remind you I have been diagnosed and being treated for Type II diabetes for almost 1 year. I also have a lower back injury, the pain has been exacerbated by my weight, including increased joint pain in my knees and ankles. I’m sure you realize no one should live this way.

Your second criteria states:

“A thorough evaluation by a multidisciplinary team for suitability and appropriateness for surgery that includes a separate medical, surgical, nutritional and mental health evaluations.”

I have followed your criteria, and all documentation was submitted to the appropriate office twice. The second of which an acknowledgement was sent that you in fact did receive all the documentation and materials necessary. I have taken considerable personal time in order to complete the required tests, and interviews. If necessary, my doctor will be more than happy to resend this information.

Finally, your third criteria states:

“Documentation of a minimum of regular, active participation in at least one recent 6-month weight loss program within the past year that is directed by a physician who does not perform weight loss surgery. Diet programs/plans such as Weight Watchers, Jenny Craig or similar plans alone would not be considered a physician-directed weight loss program. Similarly, physician-directed programs that only include pharmacological (medication) management would not be considered a physician-directed program. The submitted material must include clear evidence of at least 6 consecutive monthly visits devoted chiefly if not entirely to weight management and documentation at each of these visits of the following:

• Current weight and vital signs;
• Progress made since the last weight management visit;
• Current dietary intake;
• Current exercise program or list physical activities performed;
• Discussion of behavioral interventions used to reinforce the weight management program.”

I have been obese since my early teen years. Having experienced various diets, and exercise programs throughout my life have proven to be ineffective. I do not understand the necessity of having to prove once again that I am not capable of losing and maintaining what is considered a healthy weight. If that were possible, I would not be asking for bariatric surgery.

I did not decide to become obese. Nor did I wake up one day and decide to have weight loss surgery. I have thought long and hard about this, have done my research and discussed this at length with my family. I believe my case of medical necessity has more than been established based on your current guidelines. I am asking you to please review, and reconsider your decision.