angelsmom89

Send Message

Block

Add Friend

My name is Anita Colonia and I am insured under the above group plan.
Please consider this letter as a request for Independent Medical Review of
the denial of authorization for a vertical sleeve gastrectomy (VSG) by my
insurance company, Capital Health Plan. I requested approval for this
treatment for morbid obesity. CHP denied permission in a letter
dated10/21/10. This letter will address the reasons for denial and how I
have fulfilled the CHP requirements.  I will address why I need bariatric
surgery, as well as why I believe that the Vertical Sleeve Gastrectomy is
the most preferable of all bariatric procedures - both from my personal
medical history and, in addition why this particular procedure should be
preferable to CHP over the other choices.  Lastly, I will provide
information as to why the VSG should not be considered investigational.  I
apologize in advance for the length of this letter.  I will do my best to
make this letter concise, yet provide you with all the information needed
to make a more balanced judgment.

I have included the following informational attachments:

#1      Personal history of obesity; how it has affected my health and well
being

#2      CHP document - Reason For Denial #1

#3      CHP document - Reason For Denial #2

#4 -    CHP document - Reason For Denial #3

#5 -    CHP document - Reason For Denial #4

#6 -    CHP Denial of Appeal?????

#7 -    The Best Bariatric Operation For Older Patients (Dr.s Lee, Cirangle,
Taller, Feng and Jossart, 2005)

#8  -   Documentation showing that VSG is not investigational and improves
health outcomes, as good or better than standard alternative, or shows
improvement outside research setting - VSG widely performed and is routine
and long been performed outside the research setting

#9 -    Biggest Advantages of VSG

 

 

CHP Reasons For Denial

 

The stated reasons for denial are that the VSG is investigational, and the
CHP clinical criteria for surgical treatment of Morbid Obesity have-not
been met (as follows):
1.  There is no documentation of a 12 month weight management program.

2.  There is no documentation of life threatening co-morbid conditions that
cannot be treated safely and effectively through other means.
3.  There is no 10% weight reduction.
4.  Absence of Substance Abuse/Psychiatric Disorder Below is documentation
indicating satisfaction of CHP's Clinical Criteria for Approval.   Based on
my current medical conditions and history, and with the collaborative
advice of three separate medical professionals, feel strongly that an
exception be granted, overriding the basic denial provided by CHP as
investigational and experimental.

 

 

How CHP Criteria HAS Been Fulfilled

1.  12 month weight management program which may include primary care
services, CHP Health Coaching and/or CHP's Diabetes Prevention Weight Loss
Program - I qualify here because in April of 2009 I contacted my CHP
physician (who has recommended me for the VSG) for my weight loss issues.
She recommended me to a CHP approved weight-loss treatment Psychologist who
I have been seeing for almost 2 years. Far more than the recommended one
(1) year. (See Attachment #1)
2.  Presence of Co morbidities /Presence of severe obesity, defined as a
body mass index (BMI)*exceeding 4 or greater than 35 in conjunction with
severe co-morbidities such as cardiopulmonary complications or severe
diabetes - I qualify here because I am diabetic. I have a history of high
blood pressure. I have high cholesterol. I have sleep apnea. All of these
are being treated with medication, some very expensive. I am using a CPAP
machine for my sleep apnea; yet another cost being paid for by CHP. (See
Attachment #2)

3.  10% weight reduction - I have met this countless times, but the weight
has always rebounded, and usually with additional weight gain from
baseline.  To address maintaining weight loss, I have sought (within the
CHP network) a program with a counselor who specializes in a weight
concerns.  (People who have long term weight problems have emotional issues
to resolve. It goes far beyond just learning about nutrition. )  In the
past year and a half I have not had any significant weight gain. If you
don't have a weight problem, you may not understand how important this is.
I have developed coping skills that have aided me in not continuously
gaining weight. I believe, and my counselor will support this, that this is
a MAJOR accomplishment. These skills will aid me in maintaining my weight
and not eating around my VSG when I get it. I will not be one of those
people who regain after weight loss surgery because emotional issues were
never addressed.  Additionally, I have already contacted CHP Health
coaching to obtain a copy of "Weight Loss Surgery - Is it Right for you?” I
have completed the online Healthy Living Conversations of Healthy Weight,
Healthy Eating, and Getting Active.

 

I am still, as mentioned above, working on my weight in a healthful way, so
that it comes naturally.  (See attachment #3)

4. An adequately documented absence of active substance abuse or major
uncontrolled psychiatric disorder - Both medical records and my counselor's
records can validate this. While I do take pain medication for my injured
back, it is well controlled by a CHP pain clinic. In fact, between
epidurals, I am usually able to reduce my medication for awhile rather than
increase it beyond what the doctor had originally prescribed. Additionally,
my counselor has worked with me extensively and can validate the fact that
I do not have any uncontrolled psychiatric disorder and that I have
faithfully worked long and hard to change myself so that food is not a
first resort to manage my painful feelings. I am working hard on changing
my mindset to view food as fuel only, rather than comfort, a pain reliever,
etc. As I continue to work with my counselor, I am finding it easier to
determine if, when faced with a desire to eat, I am eating for sustenance,
habit or emotion. (See attachment #4)

Talk about benefit to back by losing weight

 

Why VSG Is Better For Me Than Current Alternatives

Although bariatric surgeries, such as the Roux-N-Y and LapBand are covered
procedures; I'm appealing for approval of the VSG as a stand-alone
procedure based on similar approvals for bariatric surgery but for
individuals who need to take anti-inflammatory medications.   (This due to
medically necessary avoidance of these medications after a Roux-en-Y (RNY)
gastric bypass because the risk of ulcer is higher.) After extensive
personal research with the collaborative advice on surgical options, my
Primary Care Physician - Dr. Vickie Erwin-Wilson, my bariatric surgeon -
Dr. Jeff Crooms, my psychologist - Dr. Jill Ricke and I all feel the VSG is
the best option for success and also the least risk comparatively.  This
especially in light of the fact that both the RNY and LapBand would be
approved without hesitation given my BMI, co-morbidities and weight
history.   Their conclusion that VSG is the best surgery for me is based on
several points. You are already in possession of letters from all three
doctors which support recommendation for surgery.

 

The VSG offers restriction like the lap-band and the RNY, but without the
malabsorption of the RNY nor the potential adverse events of RNYcombined
with oral anti-inflammatory medications.  This option was ruled out because
of the daily need for ibuprofen to address chronic back, hip pain and hand
pain for which acetaminophen is not effective.

The lap band has an adverse event percentage as high as 27% who require
removal and also does not meet weight loss goals.  More bad stuff about
LapBand.  (See Attachment #6). Conversely, the VSG removal of a large
portion of the stomach also removes many of the cells that produce the
hormone ghrelin, which is proven to cause increased hunger and appetite.
With the VSG, patients lose about 68% of excess weight and lower BMI
patients like me often do much better.  (See Attachment #7)

Weight loss will most certainly help my back and hip pain and improvability
to exercise. High cholesterol is corrected in about 76 percent of weight
loss surgery cases, and also reduces cardiovascular risk.  It’s therefore
highly likely that my health and health care costs for chronic
disease/comorbidities will be improved by this procedure.  (See Attachment
#5)

I sincerely hope this letter has provided you with the necessary
information to make a favorable decision on my need for bariatric surgery.
To sum it all up, I have complied with CHP's criteria, my health
necessitates surgery, I have made great strides in addressing the "why “of
overeating which will go a long way to ensure my future success, and
finally, the VSG truly is NOT investigational.  I respectfully ask for your
reversal of CHP's denial of my appeal.

Sincerely

Attachment #1

 I am now 54 years old. Prior to the effective date of the above plan, I
have been insured continually for the last 30 years except for a brief 2
year period. I am 5"4" tall and at the time I sought approval for this
surgery I weighed 227 lbs for a BMI of 38, almost into the morbidly obese
category. I have been overweight to one degree or another since I was a
young child and was advised by my pediatrician to diet at age 10. Prior to
that, at age 8, my mother had already started giving me the diet
supplement, "Ayds".  I have made numerous efforts at weight loss throughout
my teenage years and adult life. I have had annual physicals and other
regular medical care through out my life with weight loss by traditional
dieting being repeatedly recommended. I dieted frequently as a teenager and
young adult. Numerous times I have lost 40 pounds or more but eventually
the weight returns and then some. Weight loss programs I tried include
"Weigh Down Workshop, OverEaters Anonymous, SlimU, Food Addicts Anonymous",
traditional calorie counting on quite a few occasions, the Atkins diet,
counseling - both psychiatric (for bulimia), and nutritional, long term gym
membership, walking programs, liposuction, the Scarsdale Diet, various
buddy-system diets and individual and group therapy with a licensed
therapist. In all cases I lost weight but each time the weight crept back,
usually with a little more. Eventually I realized that traditional dieting
seemed to actually cause weight gain due to increased hunger that seems to
occur after significant weight loss. I believe science is only now
beginning to understand the reasons for this phenomenon which is
consistently reported by clinically obese people. Studies also show that
genetics plays a larger role than once thought, and there are other
morbidly obese people in my family as well as slim people.

My co-morbidities include high blood pressure, high cholesterol and back,
hip and foot pain. I take Avandia and Byetta daily for diabetes, a costly
expense for treatment of my diabetes. I take Zestril for my blood pressure.
I take Pravachol for my cholesterol, Celexa for anxiety and depression from
which I have suffered for most of my life which I believe is, to a large
extent, connected to a lifetime of obesity. I have sleep apnea and rely
upon a CPAP machine so that I don't go through my day totally exhausted.

 

My excess weight makes everyday activities difficult including housework,
shopping, standing, walking significant distances, working and recreation.
I am not able to squat down as a thinner person can, I have to spread my
legs because my knees and abdomen squish together, preventing me from
getting as low to the ground as I would like. I have to put on my shoes and
socks the same way a pregnant woman might. My obesity makes my world
smaller limiting the number of things I can do each day. I already have
some difficulty in cleaning myself properly following defecation because my
arms are short and my abdomen is large. I have lived with obesity forover50
years and strongly wish to change this aspect of my life. I fear the
consequences of my high LDL cholesterol, and further development of my
diabetes. I now have bone spurs on both my feet that are aggravated by my
weight.

I was stunned to learn that my weight is almost in the morbidly obese
category but heartened to learn of this newer (not new) procedure with
fewer side effects and shorter recovery. I have consulted with Dr. Jeffrey
Crooms, a leading bariatric surgeon who believes I would do well with the
VSG.  I am highly motivated to succeed with VSG and understand that food
intake will be significantly limited for the rest of my life and that I
must continue to exercise to be successful. I am trying to develop some of
those healthier eating habits now in anticipation of surgery. I had given
up on traditional dieting as it always resulted in further weight gain and
am pleased to have found the VSG surgical option which appears to be the
only tool offering a realistic possibility of lifelong weight control.

Attachment #8 Intro

The RNY and lap band don't have this advantage. At age 54 I am concerned
about the side effects of the RNY and do not want to spend 6 or more months
with dumping syndrome and feeling rotten. I also worry about the ability to
take and absorb other medications which I need now and might need in the
future as I age. The VSG appears to offer the fastest recovery, weight loss
similar to the RNY and the least amount of side effects. One recent
publication, "The Best Bariatric Operation for Older Patients” by Drs Lee,
Cirangle, Taller, Feng and Jossart, 2005, concludes that "These data
suggest that the best bariatric operation for older patients may be the
laparoscopic VG because it achieves the greatest weight loss with the
shortest operative time and the fewest complications". (See attachment#8)

Attachment #9 Intro

One reason for denying approval for the VSG was that it is investigational
and ..." current available medical studies do not show that this service
improves health outcomes, is as good as or better than standard
alternatives, or shows improvement outside the research setting". It is
respectfully submitted that this conclusion is incorrect. The conclusion
ignores the 36 studies now available on the effectiveness of VSG which
indicate that excess weight loss is similar to the RNY and that
complications from surgery are actually lower than RNY. It also ignores the
fact that the VSG is now widely performed and is routine for many bariatric
surgeons and has long been performed outside the research setting. (See
attachment #9)

Attachment #10 Intro

Perhaps the biggest advantage of the Vertical Sleeve Gastrectomy lies in
the fact that it does not involve any bypass of the intestinal tract so
that patients do not experience the complications of intestinal bypass
including intestinal obstruction, osteoporosis, anemia, vitamin deficiency
and protein deficiency. The Vertical Sleeve Gastrectomy is becoming the
preferred choice for many patients seeking surgical weight loss. The
portion of the stomach that produces the hormone that stimulates hunger
(Ghrelin) is removed. The stomach is reduced in volume but tends to
function normally. No dumping syndrome because the pylorus is preserved.
Minimizes the chance of an ulcer occurring so the use anti-inflammatory
drugs such as aspirin, Motrin, Aleve and ibuprofen should not be a problem.
No costly implanted devices are used (the band). It can be done
Laparoscopicly in virtually all patients and most can leave the hospital
within one day. (see attachment #10).