Question:
Could someone share their appeal letter to give me ideas on how to write one?

   — Betty S. (posted on January 31, 2003)

January 30, 2003
Betty, it might help to know specifically why you were denied. My husband was just approved on appeal with a BMI less than 40. Some pointers for writing an appeal: stick with facts and stay away from emotional responses. Use statistics to back up your argument - lab values, distances (ie, "I can only go one flight of steps without becoming so short of breath that I need 5 minutes to recover.") and so forth. Your denial letter probably says why you were denied. When responding, stick to what they are talking about. You can always add that developing heart disease or diabetes would likely be more costly to treat than if the insurance company covered WLS. Hope this helps. Email me if you would like help with a specific letter.
   — koogy

January 31, 2003
There are some at the bottom of this page http://www.insure.com/health/obesity.html
   — Jon S.

January 31, 2003
Here is the address for the one on Obesity.com. http://www.obesityhelp.com/morbidobesity/answers1.phtml?N=1043993045
   — Lana Rush

November 16, 2003
Can anyone share any information for an appeal? I was denied on Friday and all they would tell me was due to "lack of information". They wouldnt even tell me what kind of information and said to wait for the letter in the mail. I would like to have everything I need so when the letter does come and can send it back out... All help is much appreciated.
   — robin R.

December 18, 2003
Dear Sir, 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 year4,5. 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 he will continue to gain weight and the costs of co-morbid conditions, including the ones he already has and ones he 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 this gentleman. 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.
   — A M.

February 19, 2005
how to write one
   — helen S.

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