Question:
Can anyone email me a copy of an appeal letter?

My surgeon sent a letter of appeal to my insurance company and they say it does not have enough information. They want medical records...has anyone out there had to appeal and can you describe what information should be in this letter of appeal? Please help.    — Laura H. (posted on July 20, 1999)

July 20, 1999
Wish I had an answer. I'm in the same position. Please e-mail me anything you find out. Thank you very much. Warmly, Laura ([email protected])
   — Laura S.

July 20, 1999
I had problems with my insurance at first, too. I had my first consultation with my surgeon in January. They sent in the paperwork to my insurance company. I was denied in February. They wanted "actual documentation" (not just MY word) that I had been on at least three medically supervised diets for more than 12 weeks! I figured out that "medically supervised" also included the upteen times I told my doctor-----"this one didn't work either." Every thing said in his office goes on official records! I thought---I'm 50 and I've been on 1,000 "diets" in my lifetime! He HAS to have this stuff on paper! So I ordered all my medical records for the previous 5-6 years from my last three doctors. I had to pay for some of them. I went through each page that had ANY reference to---"stay on 1200 calories", "see our dietician about your diet", here's a copy of the "diabetic diet I want you on", Weight Watchers, Slim Fast, etc., etc., etc.!!!!!!! I sent a stack of paperwork an inch thick to the insurance company! (I high-lighted each reference, no matter how small!) I have never seen a an actual "letter of appeal" but I sent my own---I stated how important it was to me to do this; I tried to use logic about the monthly cost of my medication; I told them this would be cheaper in the long run than a heart attack, and finally I pleaded for them to give me the chance to extend my life! I am a VERY determined lady! I was approved the next month! Good Luck to you!
   — Jodie S.

August 15, 1999
HERE YOU GO! GOOD LUCK! Greivance and Appeals Committee Aetna Healthcare of Washington 1400 One Union Square 600 University Street Seattle, WA 98101-1158 Re: Request for standard appeal Member ID#XXXXXXXXXXXXXXXX PCP: Ramon Sanchez MD 8/8/99 Dear Mr. XXXXXXXXXXXXXX: I am writing to request pre-authorization for surgical treatment for morbid obesity. The procedure that I am leaning towards, with the surgeon's recommendation of course, is CPT Code 43846: Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (less than 100cm) Roux-en-Y gastroenterostomy. This operation has been shown to have the most beneficial outcomes, with less complications post-operatively than the other options. My preference of surgeons in order are 1-Dr Dellinger, 2-Dr Weber and 3-Dr Thirlby. I have researched these doctors and have found them to be highly recommended and without reproach. I am less than impressed with the credentials of Dr SR Fox and am not inclined to use his services. I want you to know that I am motivated, educated and determined. I have the skills, desire and tenacity to make this procedure a success. I have enclosed letters of medical necessity and recommendation for bariatric surgery from the following: Dr Donald D Hubbard, orthopedist; Dr Elizabeth Warner, psychiatrist; and Dr Fred Jackson, pulmonary medicine. I am 42 years old and weigh 310#. My waist circumference is 52". I am 5'7" and my BMI is 49+. I am "apple" shaped which has its own risk factor for adult onset diabetes and cardiovascular disease. I have a strong family history for both conditions. My history is typical of the morbidly obese. I have been on the edge of obesity since childhood. I weighed 145# (at 5'7") in high school. After graduation, marriage and having children, my weight had crept up 260# and has fluctuated between 275-328# most of my adult life. I will describe the effects and comorbidities in a moment. I have been on many supervised diets in my lifetime. Dr Richard Graham prescribed Tenuate Dospan in November of 1975. Initially, I was successfull, but, the weight returned when the medication was discontinued. Dr Hubbard referred me to Optifast in 1989 or 90 (sorry, the records have been destroyed). The program was an ultimate failure, first down 60# and then up 82# when real food was resumed. The Phen-fen medication, prescribed by Dr Sanchez in the fall of 1996, was very helpful. I lost a total of 88# (down to 222#) but it caused cardiac arrhythmias and had to be discontinued. As the weight came off , the associated co-morbid conditions improved. At 235# I could climb stairs, perform heavy exercise for a minimum of 1 hour, even RUN to codes in the hospital. When I had to discontinue the medication, my weight crept back even though I continued to eat right and exercise. At 250# the pain in my feet, knees and hips returned, interfering with exercise, my job performance and family/personal life. Eventually my weight exceeded 320#. I was now 22# heavier than when I began the medication. I have been on the following weightloss programs: Physician Supervised: Optifast, Medifast, ADA diet plan, Tenuate Dospan, Redux & Phen-fen (cardiac complications from the Phen-fen) Commercial : Nutri Systems, Jenny Craig, Weight Watchers, T.O.P.S., Health Club Memberships, Richard Simmons, Fit for Life... and every plan on the book shelf, newspaper or television. Diet Products and Plans: Top Fast, Slim Fast, Dexatrim, ADA diet plan, and any other diet, fad or otherwise, that came along. All OTC medications and supplements including "natural and herbal" Dr Ramon Sanchez has diagnosed morbid obesity and the following co morbidities: chronic back pain, sleep apnea, cardiac arrhythmias (Atrial fibrillation during Phen-fen tx and PSVT), gastroesophageal reflux, osteoarthritis of weight bearing joints, chronic severe plantar faciitis, dyslipidemia, peripheral edema, lower extremity venous stasis with at least one episode of suspected thrombosis, multiple abdominal hernias (direct and indirect), stress incontinence, asthma, shortness of breath on exertion (1 flight of stairs leaves me breathless, tachycardic and in pain because of the degenerative disease in my knees) and depression. Prior to giving his consent for the surgical treatment of morbid obesity and co-morbidities, Dr Sanchez insisted on a psychiatric opinion. I was referred to Dr Elizabeth Warner MD in February of this year for evaluation of depression, obesity (she ruled out eating or self abuse disorders) and PTSD. She diagnosed ADHD and prescribed Ritalin. Such a difference it has made. Worth particular mention is the relationship between impulse control and overeating. I believe that I can successfully maintain the weight loss and not "out eat the surgery" because of drastically improved impulse control. I am in therapy with Jere Slingerland, a clinical psychologist, to address ADHD and the multiple issues that accompany morbid obesity and weight loss such as coping skills, self image and esteem. Both professionals support the surgical intervention and believe that I am a motivated and informed patient with the skills to succeed post operatively. I am an ICU RN and can't work at my profession because of my weight and comorbidities. I graduated Bellevue Community College with honors in June 1991. I was employed immediately by Highline Hospital Intensive Care until March 1998 when I separated from HCH because of disability from a back injury. I have been self employed as a paralegal since then. I am a terrific nurse and nursing is where I belong. I have been unable to secure employment in my professional field as a direct result of my morbid obesity. My physical limitations severely discourage prospective employers from hiring me. The last was ready to hire me over the phone but "had just filled the position" after meeting me in person. I call your attention to page 25 (1. Covered Services) of the 1999 Basic Health Member Handbook. I believe that all four of the coverage criteria have been met. 1. The service is required because of a disease, illness, or injury and is performed for the primary purpose of preventing, improving, or stabilizing the disease, illness or injury. Morbid obesity is a disease (ICD-9 Code: 278.01) and the National Institute of Health Publication No. 98-4083 "Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults" specifically finds that "Gastrointestinal surgery (gastric restriction [vertical gastric banding] or gastric bypass [Roux-en Y] can result in substantial weight loss, and therefore is an available weight loss option for well informed and motivated patients with a BMI >40 or >35, who have comorbid conditions and acceptable operative risks." (page 85 of NIH Guidelines) and recommends "Surgical intervention is an option for carefully selected patients with clinically severe obesity, (BMI >40 or >35, with comorbid conditions) when less invasive methods of weight loss have failed and the patient is at high risk for obesity-associated morbidity and mortality." 2. There is sufficient evidence to indicate that the service will directly improve the length or quality of the enrollees life. Evidence is considered to be sufficient to draw conclusions if it is peer-reviewed (as defined by the National Association of Insurance Commissioners), is well-controlled, directly or indirectly relates the service to the length or quality of life, and is reproducible both within and outside of research settings. I have included Table IV-2 from the NIH report which demonstrates "Extremely high risk for disease (Type 2 Diabetes, hypertension and CVD)." We all know and the Guidelines support "...the significant impact that weight reduction on mortality" in fact "Patients undergoing the surgical procedure had a decrease in mortality rate for each year of follow up." 3. The service's expected beneficial effects on the length or quality of life outweighs its expected harmful effects. The risks of having the surgery include death. The risk of remaining morbidly obese include death. I am not making light of this fact, but I do wish to point out that with a experienced, dedicated surgeons such as Drs Dellinger, Weber or Thirbly, the risk of a poor outcome is minuscule. I am dedicated to the life time of strict adherence to dietary rules that will insure the success of this procedure. 4. The service is a cost-effective method available to address the disease, illness or injury. "Cost-effective" means there is no other equally effective intervention available and suitable for the enrollee which is more conservative or substantially less costly. The NIH study has also found that " A major limitation of nonsurgical approaches is the failure to maintain reduced body weight in many individuals." I have been on every diet, program and medication available and have experienced only limited success with each. Dr Sachez has reported to HMSO "all conservative treatment options have been exhausted." Dr DeGroot and Highline Medical Services Organization (HMSO) denied my referral to Dr Patchen Dellinger by my PCP, Dr Ramon Sanchez, on July 21, 1999. Elaine Yunker, Manager of Health Care Coordination at HMSO informed me, "We are not denying the medical necessity of this referral. We are denying the referral because it is excluded." HMSO denied the initial referral as excluded in my policy when in fact the surgical treatment for morbid obesity is not excluded. I spoke with Mary Childers at the Insurance Commissioner's Office, and she agreed that "Obesity treatment; weight loss programs" is not a specific exclusion for morbid obesity and that surgical intervention is not a "weight loss program" similar to Weight Watchers, Jenny Craig, or the other commercial diet outfits. I further inquired of Washington State Basic Health, and they agreed. In fact these procedures are authorized for Medicaid and Medicare patients without hesitation. Furthermore, surgical services are specifically covered, (page 26 of the Member Handbook) The language in the policy book is clear. We have met the "medical necessity" criteria and the procedure is not excluded. Please forward the authorization as soon as possible to the address above. (A faxed copy forwarded with the hard copy to follow would be especially considerate.) Please contact me if you require more information. Encl: letters of support, NIH excerpts, photographs and chart notes. CC: Insurance Commission Basic Health Spencer Lerner Attorney at Law
   — Iris T.

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