Denial Letter Response - ThinnerTimes

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.

Andrew · 12-04-2006, 12:51 PM

A friend of mine had their request denied as well, and had a similar BMI to you. I wonder maybe if they're starting to randomly turn people away due to the huge waiting lists. Keep pushing at it, and I wish you luck.

LisaBoston · 12-04-2006, 01:49 PM

Pat, great letter. One comment....do you think you shoud include in the last point that you just did the weight watchers program and have all the documentation to support this.

Praying that they listen this time...you are so deserving.

momronda2k · 12-04-2006, 03:32 PM

Pat, that is an awesome letter. I just had my 1 year post op appt today and Kelly at Dr. Callery's office said that insurance companies are really cracking down on approvals. She said they have gone from about 9 surgeries per week to about 4-5. Insurance companies are requiring more and more documentation, but your Doctor may be able to help you get through to them. I wish you all the luck in the world.

BethBaugh · 12-05-2006, 09:16 AM

The letter is great but the last point will be your downfall in my opinion. Didn't your doctor suggest the diet you went on. I suggest you get the documentation from the weight loss service and a letter from your doctor stating that he/she recommended this. Then put in any info from your doc that you checked in with him/her too.

Huggs and prayers
Beth B. in TN

Baron Patrick · 12-05-2006, 09:56 AM

Thanks for the suggestions. I made some revisions (in bold):

I have been obese since my early teen years. Having experienced various diets, and exercise programs throughout my life have proven to be ineffective. My doctor instructed me to join Weight Watchers, as it was her understanding this will satisfy your requirements. I have been diligent in ensuring I completed this six-month monitoring, along with periodic follow-up with my doctor. This documentation was also submitted to you.

I did not decide to become obese. Nor did I wake up one day and decide to have weight loss surgery. I have researched bariatric surgery for over a year, 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.

Tracie · 12-05-2006, 10:44 AM

Quote:

Originally Posted by Baron Patrick

Thanks for the suggestions. I made some revisions (in bold):

I have been obese since my early teen years. Having experienced various diets, and exercise programs throughout my life have proven to be ineffective. My doctor instructed me to join Weight Watchers, as it was her understanding this will satisfy your requirements. I have been diligent in ensuring I completed this six-month monitoring, along with periodic follow-up with my doctor. This documentation was also submitted to you.

I did not decide to become obese. Nor did I wake up one day and decide to have weight loss surgery. I have researched bariatric surgery for over a year, 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.

Patrick,

I would let them know that you have researched for almost 2 years...(after all, you joined this group 19 months ago!) I am sooo frustrated for you. I am so proud of you for being persistant. It will pay off, it's got to!

coptergirl · 12-05-2006, 11:59 AM

My concern when i read it was something already mentioned and fixed - your doctor told you to go to WW, and monitored you throughout the process. Did the ins co's stipulation always say that WW was no accepted, or didn't they change in the middle of your process? That would be something else to bring up...

I am crossing all sorts of body parts that this works for you - you deserve this after researching and fighting for 2 years!!! Man will your hospital room be over full with visitors

Zenomia · 12-05-2006, 01:06 PM

Quote:

Originally Posted by Baron Patrick

Thanks for the suggestions. I made some revisions (in bold):

I have been obese since my early teen years. Having experienced various diets, and exercise programs throughout my life have proven to be ineffective. My doctor instructed me to join Weight Watchers, as it was her understanding this will satisfy your requirements. I have been diligent in ensuring I completed this six-month monitoring, along with periodic follow-up with my doctor. This documentation was also submitted to you.

I did not decide to become obese. Nor did I wake up one day and decide to have weight loss surgery. I have researched bariatric surgery for over a year, 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.

You might want to add that you discussed it not only with your family, but your physician. Try, though I know it's hard, to keep the personal sentiments OUT of your letter for appeal. Instead of saying this documentation was submitted, say instead that you will include the documentation required. (Even though it has been provided previously...they won't want to search for anything...if it's at their fingertips, it won't get sidelined!) Also, a letter from your physician, stating plainly that you have been monitored for more than just the 6 months for weight and weight related health issues...ie: Type 2 Diabetis, will do a lot more to forward your case.

I have learned that they insurance companies don't care about your feelings or what you have gone through, they don't see you as a person. They see you as a Bottom line, and as such, you need to approach this letter as what you have done and how you have accomplished all their hoops and then some. They won't care about your 'feelings' they care about your Drs. reports, and your proof that you did what they deemed as 'required' for surgery and then some. I don't mean to sound discouraging, I just want you to have the best possible chance at getting this approval that you can!!

You have worked way to hard at this Pat....don't give up now....hop, skip and jump...they will HAVE to take you!! Soon sweetie...soon!!

Baron Patrick · 12-05-2006, 02:47 PM

Whitney - I called them and their representative said it was okay. I added this in my letter. Thank you.

Zen - You don't sound discouraging, I appreciate your comments! I took out all the "emotional" parts, and tried to use a bit stronger language.

Here is the full, revised letter:

Cigna HealthCare December 5, 2006
National Appeals Unit
P.O. Box 5225 Scranton, PA 18505-5225

This is in response to the letter your letter dated November 14, 2006 denying approval for Gastric Bypass surgery.

Member Name: Patrick S Burke
DOB: 12/26/1957
Member ID#: U05469010-01
Health Plan Name: CIGNA HealthCare of California, Inc.
Requested Provider: Inland Valley Medical Center
Requested Service: 43644 Laparoscopic Roux-En-Y Gastric Bypass
Requesting Provider/Physician: Dr. David Suh
Authorization Request Reference#: BTL26TK1

As stated in the denial letter by Ajani Nimmagadda, 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 a BMI consistently between 45 and 50. My current BMI is 45.5. I’m confident you are acutely aware how obesity significantly diminishes one’s quality of life, health, finances, and a reduced life span.

Based on your criteria, I am not required to prove co-morbidities as my BMI is over 40. However, in order to help you to make an informed decision, I must remind you I have been diagnosed and being treated for Type II diabetes for nearly 1 year. I also have a lower back injury; the pain being exacerbated by my weight, including joint pain in my knees and ankles. These have all been documented by my doctor.

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 fulfilled all your criteria, and all documentation has been submitted to your office twice. Your office also sent an acknowledgement stating you have received the required documentation. If necessary, my doctor will be more than happy to resubmit this information, again.

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 in the long term.

My doctor instructed me to join Weight Watchers, as she was certain this will satisfy your requirements. I also called Cigna and asked specifically if Weight Watchers is acceptable, and was told yes by your insurance representative. I have been diligent in ensuring I completed this six-month monitoring, along with periodic follow-up with my doctor. This documentation has also been submitted for your review.

I have researched bariatric surgery for over a year and a half, and discussed this at length with my family, my doctor, and surgeon. I believe my case of medical necessity has more than been established based on your guidelines. I respectfully request you to please review, and reconsider your decision.