My second level of appeal

Hey there ladies, If you all would be so kind and review these letters for me I would appreciate it. The First one is my original appeal and the second I have not sent but need to ASAP so give me some advice.

May 20, 2008  Meleta Getman  xxxxxxxxxxxx

Ozark, MO 65721 Attn: Med-Pay  Re: Meleta Getman ID#xxxxxx Group #xxxxxxOCC 2-11-1970   

To whom it may concern:  

I am writing you in response to your denial of the claim for the gastric bypass surgery to treat my co-morbidities whi*****lude high blood pressure, borderline diabetic, fatty liver, high cholesterol, borderline sleep apnea and reflux.  Your company has denied coverage for this treatment for the following reasons listed: BMI is below required criteria.  I am submitting the claim for reconsideration.  This letter provides information about my medical history and diagnosis. I was referred to Dr. Chris Edwards who is the Bariatric surgeon in our area by my primary physician Dr. Rachelene Middleton. Gastric Bypass surgery has proven to greatly improve high blood pressure, high cholesterol, heart disease, diabetes, asthma, respiratory insufficiency, sleep apnea syndrome, Gastroesophageal reflux disease, gallbladder disease, stress urinary incontinence, low back pain, degenerative disc disease, and degenerative joint disease.  Successful treatment improves the patients over all health. I have been overweight since I was 18 years old and have tried Weigh****chers 4-5 times with some success but with weight gained back, doctor prescribed weight loss medication such as Phen-Fen and later just the Phentermine, Atkins diet, soup diet, South beach diet and just trying to watch what I eat and several others. These have all resulted in the original weight gained back with additional weight gained. My current weight is 206 and stays around this within a 4-9 lbs fluxuation. I have seen the nutritionist and exercise consultants for the past month or so and my weight was 203 the first time which put my BMI at 39 (just below the required BMI) and then my last visit with Amy Blansit the exercise consultant my weight was 206 which put my BMI at 40.2. Other than the current conditions that I have my family medical conditions are as serious as my current medical conditions. My mother has had 3 heart attacks with 6 stints put in over the last 5-7 years and had a major stroke at the age of 42 and several mini strokes associated with coronary artery disease. My aunt on my mothers’ side also has had 2 heart attacks and is a diabetic. The request for the approval of the surgery is as important to my health not in as much as my BMI being largely over the required BMI but my medical conditions are a hindrance to my health and life in general.   

The history of my current medication is as follows:  

High Blood pressure currently taking amlodipine 2.5 mg daily Borderline diabetic currently taking metformin 500 mg daily  Acid reflux currently taking omeprazole 20 mg daily  Anxiety/Depression/weight loss currently taking wellbutrin   

Gastric Bypass surgery is indicated for the treatment of patients who have such medical conditions as high blood pressure, high cholesterol, heart disease, diabetes, asthma, respiratory insufficiency, sleep apnea syndrome, Gastroesophageal reflux disease, gallbladder disease, stress urinary incontinence, low back pain, degenerative disc disease, and degenerative joint disease.  Successful treatment improves the patients over all health. Gastric Bypass was endorsed by the National Institutes of Health Consensus Conference, 1992.[1] The American Society for Bariatric Surgery (ASBS) has a representative on the American College of Surgeons Board of Governors and is a specialty surgical society in the Specialty & Service Society section of the American Medical Association.  There is ample clinical literature to support the gastric bypass for the treatment of the above referenced conditions.  In summary, the gastric bypass is medically necessary and reasonable and warrants coverage.  Please contact me if you require additional information.   

Sincerely,  Meleta Getman Second letter

June 20, 2008  ATTN: Controller Ozarks Coca-Cola/Dr. Pepper Bottling Company  P.O. Box 11250

(1777 N. Packer Rd.) Springfield, MO 65808 (65803)    Meleta Getman  2-11-1970  Med-Pay ID#XXXXXX Group #XXXXXXOCC  Dear Controller:   I am writing this letter to appeal Med-Pay’s decision to deny coverage for Roux-en-Y gastric bypass surgery. Based on the first level grievance letter of denial dated June 13,2008, this procedure was denied because “Although this BMI recorded on May 14, 2008 is 40, a transient reaching of that one guideline does not meet the level of standards of medical care also required by the group health plan. Based upon the standards of medical practice and the plan requirement of a BMI of 40 or greater, we are unable to authorize benefits for Roux-en-Y gastric bypass.” Although my BMI has been “transient” for the last 15 years it has been continuously well over the National Health Institutes set guideline which Med-Pay stated was the determining standards of medical care for weight reduction and bariatric surgery.  Please review my health history per my original appeal letter to Med-Pay as well as my doctor’s letter. These will also show my previous many attempts and methods of weight loss treatment require by your plan. At this time, my doctor Dr. Rachelene Middleton believes that the Roux-en-Y gastric bypass is medically necessary and will significantly benefit my health. I have had many of my medical history details mailed/faxed to Med-Pay and also drug therapy prescriptions dating back to 10-4-06.   As per the plan document it states only that “In order to be eligible for gastric bypass, the Covered Person’s BMI must be 40 or greater.” This does not state for any period of time or that weight changes excludes you. All topics that the included letter of denial state that are required per the plan I have and do meet but the plan does not state that transient or fluxing weight changes excludes or would not be covered. The letters included state facts about my health and conditions that I currently have and also the attempts that I have made over several years to try and permanently lose the weight.  My overall health would still benefit from the surgery with the possibility of not having to take medication any longer and having a lot less risk for other complicating conditions that I also feel that I have expressed that are heredity in my family such as the coronary heart disease. I also sent to Med-Pay a report from the St. John’s hospital from July of 2007 where I have had a sleep apnea study and it was determined that I did have a moderate amount of sleep apnea but not to the extent of requiring a c-pap machine.  I also believe as per the standards of medical care considered for bariatric surgery that I would be an ideal patient having no major preoperative risk factors, a stable personality, no eating disorders and am able to lose some weight prior to surgery to make the surgical intervention easier and that it would be an indication of the likelihood of compliance with the severe dietary restriction imposed on patients following surgery. According to the NHI Gastric Bypass surgery is indicated for the treatment of patients who have such medical conditions as high blood pressure, high cholesterol, heart disease, diabetes, asthma, respiratory insufficiency, sleep apnea syndrome, Gastro esophageal reflux disease, gallbladder disease, stress urinary incontinence, low back pain, degenerative disc disease, and degenerative joint disease.  Successful treatment improves the patients over all health. Gastric Bypass was endorsed by the National Institutes of Health Consensus Conference, 1992.[1] The American Society for Bariatric Surgery (ASBS) has a representative on the American College of Surgeons Board of Governors and is a specialty surgical society in the Specialty & Service Society section of the American Medical Association.  As per your health plan definitions and requirement stated I have met and do meet the requirements for the Roux-en-Y gastric bypass surgery.  Based on this information, I am asking that you reconsider the denial and approve coverage for the Roux-en-Y gastric bypass surgery. If you need any additional information, please contact me at xxx-xxx-xxxx.  Thank you for your time and attention to this matter.  Sincerely,  Meleta Getman  xxxxxxxxxxxxxx

Ozark, MO 65721  417-xxx-xxxx Please help me!! I don't want to use up all my appeals!

 

 

 

 

 

 

You have written an excellent letter, I personally would not put the part in there about agreeing that the medication is keeping your co-morbidies under control, why draw attention to that and give them ammunition? focus on the fact that you have met their criteria per their policy, and unless they are have added an addendum to it, they should be approving it. good luck to you, I hope more pople chime in to give some good advice, btw someone mentioned an atty that Dr H recommends, I would send him an e-mail just to feel him out, can't hurt to try, usually an atty, will give you a free or low cost intial appt. good luck, Susan

I have posted on the Main Board and the Light Weight Board trying to find help.  I did find this page, not sure if you've seen it.  http://www.obesityhelp.com/morbidobesity/information/wlsjour ney/insurance+trouble.php People have mentioned wearing ankle weights to a documented weigh in.  I would defenitly do this!  I know it's cheeting, but hey. . . your insurance is being difficult, so I say all's fair.   here are a couple of the responces I have recieved back from my posts.     

I don't know what else she could do as far as a letter goes. My only suggestion, stupid as the idea sounds, is to get 6 months documentation of a BMI over 40 and submit that. She will have to make an effort to gain a few pounds and keep her weight high enough to qualify, and then re-submit. I did this last summer so that I wouldn't have to do a 6 month supervised diet and could just get immediate approval. I was surprised how hard it was to actually gain a few pounds and try to keep it up there! Evidently it is only easy to gain weight when you don't want to! -Wanda

 

 

 

Get all the documentation you can grasp your hands on. I to was worried I would not get approved due to my being boarder-line weight/BMI at the time. For the 9 months to come,while going to all the wonderful classes and such for surgery I made sure to maintain the weight and add a couple pounds on as able to be able to get approved. It was so hard! People would look at me during breaks as if why is she eating that food? and chips? and candy? I was so on a mission! Little did they know and for that matter little do they still know! I choose not to tell people at work (only the ones I work direct with) So document,document and more document! Your Doctor should also be helping you get things organized for this. At least ours do here. Best of luck  Kelly

 

 

 

A lot of folks have to fight with insurance but some of us have been real lucky with ours too. Have you gone over to the insurance board and asked for help there? I think a good resource might be the ASBS web site that recommends WLS for folks with BMIs of 35 or more with co-morbidities. She can snag the info right from there. I have a copy of a big appeal issue I got from one of my DSr guys, but it might not be much help. That appeal was trying to get an insurance company to approve a DS rather than an RNY. Let me look around a bit and I'll PM you back if I find anything.
Gina

  I hope some of this helps.   Good Luck to you & DON'T GIVE UP!!!      (((HUGS)))   Angy